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Settlement Agreement
Settlements are a commonplace event in workers’ compensation claims. The settlement will be presented to the administrative tribunal and will be in writing. Making sure all of the specifics are included and accurate will prevent misunderstandings between the parties and will allow the magistrate to make an informed decision.
As a paralegal, ask yourself the following questions:
- What should be included in a standard settlement agreement?
- Who should write a settlement agreement, the plaintiff or the defendant? Why?
You participate, with your supervising attorney, in a settlement conference on behalf of your client, an 80-year-old man. He has been awarded 500 weeks of compensation at $400 per week. He wants to settle the claim for a lump sum instead of the periodic payment. Draft a valid and enforceable settlement agreement, under the supervision of your attorney, outlining your client’s withdrawal of his claim in exchange for a lump sum payment of $100,000.
Click
here
to download the draft to request a lump sum settlement.
On a separate page, cite all sources using the Bluebook format.
Illinois Workers’ Compensation Commission
Settlement Contract LUMP SUM PETITION AND ORDER
Attention. Please type or print. Answer all questions. File four copies of this form. Attach a recent medical report.
Workers’ Compensation Act FORMCHECKBOX
Occupational Diseases Act FORMCHECKBOX
Fatal case? No FORMCHECKBOX
Yes FORMCHECKBOX
Date of death
Case #
WC
Employee/Petitioner
v.
Setting
Employer/Respondent
To resolve this dispute regarding the benefits due the petitioner under the Illinois Workers’ Compensation or Occupational Diseases Act, we offer the following statements. We understand these statements are not binding if this contract is not approved.
Employee’s name
Street address
City, State, Zip code
Employer’s name
Street address
City, State, Zip code
Employee’s Social Security #
Male FORMCHECKBOX
Female FORMCHECKBOX
Married FORMCHECKBOX
Single FORMCHECKBOX
# Dependents under age 18
Birthdate
Average weekly wage $
Date of accident
How did the accident occur?
What part of the body was affected?
What is the nature of the injury?
The employer was notified of the accident orally FORMCHECKBOX
in writing FORMCHECKBOX
.
Return-to-work date
Location of accident
Did the employee return to his or her regular job? Yes FORMCHECKBOX
No FORMCHECKBOX
If not, explain below and describe the type of work the employee is doing, the wage earned, and the current employer’s name and address.
Temporary Total Disability Benefits: Compensation was paid for
weeks at the rate of $
/week.
The employee was temporarily totally disabled from
through
Medical Expenses: The employer has FORMCHECKBOX
has not FORMCHECKBOX
paid all medical bills. List unpaid bills in the space below.
Previous agreements: Before the petitioner signed an Attorney Representation Agreement, the respondent or its agent offered
in writing to pay the petitioner $
as compensation for the permanent disability caused by this injury.
An arbitrator or commissioner of the Commission previously made an award on this case on
regarding
TTD FORMCHECKBOX
Permanent disability FORMCHECKBOX
Medical expenses FORMCHECKBOX
Other FORMCHECKBOX
IC5 12/04 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611 Toll-free 866/352-3033 Web site: www.iwcc.il.gov
Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084
Disclosure of this information to the Commission is done voluntarily under 820 ILCS 305/6(b).
Terms of settlement: Attach a recent medical report signed by the physician who examined or treated the employee.
Total amount of settlement
$
Deduction: Attorney’s fees
$
Deduction: Medical reports, X-rays
$
Deduction: Other (explain)
$
Amount employee will receive
$
Petitioner’s signature. Attention, petitioner. Do not sign this contract unless you understand all of the following statements.
I have read this document, understand its terms, and sign this contract voluntarily. I believe it is in my best interests for the Commission to approve this contract. I understand that I can present this settlement contract to the Commission in person. I understand that by signing this contract, I am giving up the following rights:
1.
My right to a trial before an arbitrator;
2.
My right to appeal the arbitrator’s decision to the Commission;
3.
My right to any further medical treatment, at the employer’s expense, for the results of this injury;
4.
My right to any additional benefits if my condition worsens as a result of this injury.
_________________________
Signature of petitioner
Name of petitioner (please print)
Telephone number
Date
Petitioner’s attorney. I attest that any fee petitions on file with the IWCC have been resolved. Based on the information reasonably available to me, I recommend this settlement contract be approved.
_________________________________
Signature of attorney
Date
Attorney’s name and IC code # (please print)
Firm name
Street address
City, State, Zip code
Telephone number
E-mail address
Respondent’s attorney. I attest that any fee petitions on file with the IWCC have been resolved. The respondent agrees to this settlement and will pay the benefits to the petitioner or the petitioner’s attorney, according to the terms of this contract, promptly after receiving a copy of the approved contract.
_________________________________
Signature of attorney or agent
Date
Attorney’s name and IC code # or agent (please print)
Firm name
Street address
City, State, Zip code
Telephone number
E-mail address
Name of respondent’s insurance or service company (please print)
Order of arbitrator or commissioner:
Having carefully reviewed the terms of this contract,
in accordance with Section 9 of the Act, by my stamp
I hereby approve this contract, order the respondent
to promptly pay in a lump sum the total amount of
settlement stated above, and dismiss this case.
IC5 page 2
