(a) The settlement application shall be a self-sufficient document
which can be evaluated without further reference to the administrative
file. The application shall be in the form of a stipulation signed by
all parties and shall contain a brief summary of the facts of the case
to include: a description of the incident, a description of the nature
of the injury to include the degree of impairment and/or disability, a
description of the medical care rendered to date of settlement, and a
summary of compensation paid and the compensation rate or, where
benefits have not been paid, the claimant's average weekly wage.
(b) The settlement application shall contain the following:
(1) A full description of the terms of the settlement which clearly
indicates, where appropriate, the amounts to be paid for compensation,
medical benefits, survivor benefits and representative's fees which
shall be itemized as required by Sec. 702.132.
(2) The reason for the settlement, and the issues which are in
dispute, if any.
(3) The claimant's date of birth and, in death claims, the names and
birth dates of all dependents.
(4) Information on whether or not the claimant is working or is
capable of working. This should include, but not be limited to, a
description of the claimant's educational background and work history,
as well as other factors which could impact, either favorably or
unfavorably, on future employability.
(5) A current medical report which fully describes any injury
related impairment as well as any unrelated conditions. This report
shall indicate whether maximum medical improvement has been reached and
whether further disability or medical treatment is anticipated. If the
claimant has already reached maximum medical improvement, a medical
report prepared at the time the employee's condition stabilized will
satisfy the requirement for a current medical report. A medical report
need not be submitted with agreements to settle survivor benefits unless
the circumstances warrant it.
(6) A statement explaining how the settlement amount is considered
adequate.
(7) If the settlement application covers medical benefits an
itemization of the amount paid for medical expenses by year for the
three years prior to the date of the application. An estimate of the
claimant's need for future medical treatment as well as an estimate of
the cost of such medical treatment shall also be submitted which
indicates the inflation factor and/or the discount rate used, if any.
The adjudicator may waive these requirements for good cause.
(8) Information on any collateral source available for the payment
of medical expenses.
(Approved by the Office of Management and Budget under control number
1215-0160)
[50 FR 399, Jan. 3, 1985, as amended at 51 FR 4284, Feb. 3, 1986]
