K-Wc Form D - Settlement Agreement - Final Receipt And Release Of Liability

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KANSAS DEPARTMENT OF LABOR
SETTLEMENT AGREEMENT –
FINAL RECEIPT AND RELEASE OF LIABILITY
K-WC Form D (Rev. 3-14)
MAIL: Division of Workers Compensation
401 SW Topeka Blvd., Suite 2
Topeka, KS 66603-3105
FAX: (785) 296-8580
The Kansas Workers Compensation law provides that compensation due may be settled by agreement and
that the employer is entitled to a receipt and release of liability upon final payment of compensation due,
and that such final receipt and release of liability shall be filed by the employer in the office of the Director
of Workers Compensation within sixty (60) days after the date of the execution of the same, and that such
agreement, final receipt and release of liability is made subject to the approval of the Director that the correct
amount of compensation has been paid as required by law, and will automatically become approved by law
unless disapproved by the Director within twenty (20) days of the date it is received by that office.
COMPLETION OF THIS REPORT IS REQUIRED BY LAW.
51-3-2 Final receipt and release of liability. A final receipt and release of liability shall cover all
compensation paid and shall not be taken until the disability has terminated, or in case of permanent partial
disability, until a final determination of the percentage of that permanent partial disability can be definitely
ascertained. No compromise settlements shall be made on a final receipt and release of liability. The
physician's report or reports accompanying the final receipt and release of liability shall conform to the amount
paid for the disability except when the rating is an average of the ratings expressed by the doctors.
Dates and figures required shall be specific and accurate, and only in exceptional instances where explanation
is necessary may insertions or additions be made.
The final receipt and release of liability shall be signed by the claimant and the signature shall be notarized.
The final receipt and release of liability form shall be accompanied by a physician's final report and by an
accident report if the report has not already been filed with the Division of Workers Compensation.
(Authorized by K.S.A. 44-573; implementing K.S.A. 44-527; effective Jan. 1, 1966; amended Jan. 1, 1973;
amended Feb. 15, 1977; amended May 1, 1978; amended May 1, 1983; amended June 21, 2002.)
NOTE (1): A physician's final report must accompany this agreement when it is filed with the Director for approval.
NOTE (2): No compensation other than medical is payable for the first week following the injury, except cases of
amputation or death, unless temporary total loss continues for three consecutive weeks.
Federal Privacy Act Disclosure Section 7(a)(2)(B)
The mandatory requirement that Social Security numbers be included on forms filed with the Division of Workers
Compensation is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, since our regulations which
require its disclosure were in existence before January 1, 1975. The number is used as a means of identifying
all the various records in the Division of Workers Compensation pertaining to an individual.
The use of Social Security numbers is made necessary because of the large number of applicants who have
similar names and birth dates, and whose identities can only be distinguished by the Social Security number.
DIVISION OF WORKERS COMPENSATION
401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 • Phone: (785) 296-4000 • Fax: (785) 296-8580

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