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Home >Board Forms> Lump Sum Settlement Instructions

LUMP SUM SETTLEMENT, WCB-10

The employer, insurer, third-party administrator, employee, and/or attorney files the Lump Sum Settlement form to request approval of a lump sum settlement.

The Lump Sum Settlement is a four-part form. The distribution is as follows:

Copy 1 to the Workers’ Compensation Board.
Copy 2 to the Employee.
Copy 3 to the Insurer.
Copy 4 to the Employer.

INSTRUCTIONS FOR COMPLETING LUMP SUM SETTLEMENT, WCB-10

Identifying Information

  1. Insurer File Number
    This box is provided for use by the insurer. If the insurer file number is known at the time the Lump Sum Settlement is filed, enter it here. The Board will record it for reference.
  2. Employer Name
    Enter the employer name as it was entered in box 10 of the Employer’s First Report of Occupational Injury or Disease, WCB-1.
  3. Employer Mailing Address and Phone Number
    Enter the address where the employer receives mail. Also enter the employer’s phone number, including area code.
  4. Insurer
    Enter the name of the employer’s workers’ compensation insurer, self‑insurer, or third‑party administrator if there is one.
  5. Insurer Mailing Address
    Enter the insurer, self-insured, or third-party administrator’s mailing address.
  6. Social Security Number
    Enter the employee's social security number.
  7. WCB File Number
    If the preparer knows this number, enter it here. Doing so will speed up processing this form.
  8. Employee Last Name
    Enter the employee's last name as entered in box 27 of the Employer's First Report of Occupational Injury or Disease, WCB‑1.
  9. First Name
    Enter the employee's first name as entered in box 28 of the Employer's First Report of Occupational Injury or Disease, WCB‑1.
  10. M.I.
    Enter the employee's middle initial as entered in box 29 of the Employer's First Report of Occupational Injury or Disease, WCB‑1.
  11. Address – Number and Street
    Enter employee's mailing address.
  12. City
    Enter city of employee's mailing address.
  13. State
    Enter state of employee's mailing address.
  14. Zip
    Enter zip code of employee's mailing address.
  15. Home Phone Number
    Enter employee's home telephone number, including area code.
  16. Date of Injury
    Enter the date of injury. This date should be the same as box 42 of the Employer's First Report of Occupational Injury or Disease, WCB‑1.
  17. Description of Injury
    Enter a complete description of the injury.

Type of Settlement

  1. Check the box that describes the type of settlement. If the settlement is structured, attach the appropriate documentation. If the settlement is a straight lump sum, enter the total value.

Permanent Impairment Rating

  1. If known, enter the percentage of whole body permanent impairment rating and the amount paid.

Comments

  1. Use this box to enter any additional information that might be pertinent to the claim.

Preparer Information

  1. Preparer Name and Title
    Type or print the preparer’s name and title.
  2. Telephone Number
    Enter the preparer’s telephone number, including area code.
  3. Date
    Enter the date this form is completed.

Release

  1. This box is for the employee/dependent, attorney(s), insurer, third-party administrator, and employer to sign and date, whether or not they agree with the requested lump sum settlement.

Decision

  1. This box is to be used only by the Hearing Officer.

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