WORKERS' COMPENSATION CREDIT/OFFSET CALCULATION WORKSHEET

Case Name: [________________________________]
Case/Claim Number: [________________________________]
Date of Injury: [__/__/____]
Date Prepared: [__/__/____]
Prepared By: [________________________________]

SECTION 1: CASE OVERVIEW

Workers' Compensation Claim Information:

Third-Party Case Information:

SECTION 2: JURISDICTIONAL RULES

State: [____]

Applicable Statute:

[________________________________]

Type of Recovery System:

☐ Subrogation/Reimbursement System
- WC carrier has direct claim against third party or reimbursement from employee's recovery

☐ Credit/Offset System
- Employer entitled to credit against future benefits for third-party recovery

☐ Hybrid System
- Both lien reimbursement and future credit apply

Key State Rules:

Attorney Fee Allocation:
☐ WC lien reduced by proportionate share of attorney fees
☐ Statutory formula for fee allocation: [________________________________]
☐ No fee allocation required

Employer Fault Consideration:
☐ Witt v. Jackson or similar rule applies
☐ Employer negligence reduces lien/credit
☐ Employer fault not considered

Made Whole Doctrine:
☐ Applies - Employee must be made whole first
☐ Does not apply - WC recovers first dollar
☐ Modified: [________________________________]

SECTION 3: WORKERS' COMPENSATION BENEFITS PAID

A. Medical Benefits Paid to Date:

B. Indemnity Benefits Paid to Date:

C. Other Benefits Paid:

D. Total Benefits Summary:

SECTION 4: ESTIMATED FUTURE BENEFITS

A. Future Medical Benefits:

B. Future Indemnity Benefits:

C. Total Estimated Future Benefits:

SECTION 5: THIRD-PARTY RECOVERY

Settlement/Verdict Information:

Detailed Cost Breakdown:

SECTION 6: LIEN/CREDIT CALCULATION

Method 1: Standard Lien Calculation

Attorney Fee Reduction Calculation:

Method 2: Net Recovery Formula (Common in Many States)

SECTION 7: EMPLOYER NEGLIGENCE ANALYSIS (Witt v. Jackson)

Does Employer Share Fault for Injury?

☐ Yes - Employer contributed to causing injury
☐ No - Employer not at fault
☐ Uncertain - Further analysis needed

If Employer At Fault:

Lien Reduction for Employer Fault:

Applicable State Law on Employer Fault:
[________________________________]
[________________________________]

SECTION 8: FUTURE CREDIT CALCULATION

Credit Against Future Benefits:

Credit Application:

How Credit Works:
If employee's net recovery exceeds zero, employer may be entitled to credit against future WC benefits equal to employee's net recovery amount.

SECTION 9: DISTRIBUTION WORKSHEET

Settlement Distribution:

Credit Holdback (if applicable):

SECTION 10: STATE-SPECIFIC FORMULAS

Common State Approaches:

New York (Kelly/Burns Formulas):

☐ Kelly Formula (Schedule Loss of Use, PTD, Death, Benefits Terminated)
☐ Burns Formula (Continuing PPD Benefits)

Kelly Formula:
Net Recovery × (WC Lien ÷ (WC Lien + Claimant's Damages Excluding WC Paid)) = WC Share

Burns Formula:
Different allocation between past and future benefits

California (Labor Code § 3861):

Other State Formula: [________________________________]

SECTION 11: NEGOTIATION TRACKING

Lien Negotiation:

Resolution:

SECTION 12: APPROVAL AND DOCUMENTATION

Required Approvals (Varies by State):

☐ Workers' Compensation Board/Commission approval required
☐ Employer/carrier consent obtained
☐ Court approval of settlement allocation
☐ Compromise and release filed
☐ Other: [________________________________]

Documentation Checklist:

☐ WC benefit printout (complete)
☐ Third-party settlement agreement
☐ Attorney fee agreement
☐ Litigation cost itemization
☐ Employer fault analysis (if applicable)
☐ State-specific calculation worksheet
☐ WC carrier lien letter
☐ Lien reduction agreement
☐ Distribution statement
☐ Release from WC carrier
☐ WC Board approval (if required)

SECTION 13: SUMMARY

Final Numbers:

CERTIFICATION

I certify that this workers' compensation credit/offset calculation is based on available benefit records, applicable state law, and the third-party recovery in this matter. This worksheet is for settlement calculation purposes.

Signature: ________________________________________ Date: [__/__/____]

Print Name: [________________________________]

Title: [________________________________]

SOURCES AND REFERENCES

• Sullivan on Comp: Credit for Third-Party Recovery
• Advocate Magazine: Lien Management in WC and Civil Cases
• CLM Magazine: Recovering a Workers' Compensation Lien
• State-specific workers' compensation statutes
• MWL Law: Documenting WC Statutory Credits in All 50 States

This worksheet is for informational purposes only. Workers' compensation lien and credit rules vary significantly by state. Consult legal counsel regarding applicable state law and specific calculation requirements.