Compromise Agreement Summary Page 2
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1
2COMPROMISE & RELEASE AGREEMENT SUMMARY (Continued from Front)
30. Summarize Payments Made to Date or Attach a Compensation Report with a Total Payment History.
a. Compensation (Complete a separate line for different rates, types or disability interruptions):
TYPE
FROM
THROUGH
WEEKS & DAYS
WEEKLY RATE
TOTAL AMOUNT
LUMP SUM
b. Medical:
c. Other (Explain):
TOTAL
Amount:
COMPENSATION:
31. Agreed Settlement.
a. Compensation (Complete a separate line for different rates, types or disability interruptions):
TYPE
FROM
THROUGH
WEEKS & DAYS
WEEKLY RATE
TOTAL AMOUNT
LUMP SUM
b. Medical Benefits Released?
TOTAL
NO
YES, Amount:
COMPENSATION:
Paid By:
d. Vocational Rehabilitation Benefits Released?
c. Attorney's Fees:
Employer
Employe
NO
YES, Amount:
e. REMARKS:
f. Total Agreed Settlement Amount:
32. Submitted By (Name of Person and Company or Firm):
33. Date:
FOR AWCB USE ONLY
34. COMMENTS:
35. DISPOSITION:
APPROVE
DISAPPROVE
REQUEST INFORMATION
RECOMMENDED HEARING
36. By:
37. Date:
Form 07-6117 (Rev 04/2010)
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