STIPULATIONS WITH REQUEST FOR AWARD

(Workers' Compensation Settlement - Future Medical Treatment Open)

[// GUIDANCE: A Stipulated Award (Stips) is a settlement where the parties agree on the permanent disability rating and indemnity benefits, BUT future medical treatment remains OPEN. Unlike a Compromise and Release, the injured worker retains the right to receive medical treatment for the industrial injury. Most states allow reopening for new and further disability within a specified period (e.g., 5 years in California).]

PART 1: CASE IDENTIFICATION

WCAB/BOARD CASE NUMBER: [ADJ NUMBER]

CLAIM NUMBER: [NUMBER]

DATE OF INJURY: [DATE]

SPECIFIC OR CUMULATIVE: ☐ Specific ☐ Cumulative Trauma
If Cumulative, Period: [DATE] through [DATE]

PART 2: PARTIES

2.1 Injured Worker (Applicant)

Name: [FULL LEGAL NAME]

Social Security Number: [XXX-XX-XXXX]

Date of Birth: [DATE]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Occupation: [JOB TITLE]

2.2 Employer (Defendant)

Name: [EMPLOYER LEGAL NAME]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

2.3 Insurance Carrier

Name: [CARRIER NAME]

Policy Number: [NUMBER]

Claims Administrator:
[ADDRESS]
[CITY], [STATE] [ZIP CODE]

PART 3: ATTORNEYS

Applicant's Attorney:
Name: [NAME]
Bar No.: [NUMBER]
Firm: [FIRM]
Address: [ADDRESS]
Phone: [PHONE]

☐ Applicant is unrepresented (pro per)

Defendant's Attorney:
Name: [NAME]
Bar No.: [NUMBER]
Firm: [FIRM]
Address: [ADDRESS]
Phone: [PHONE]

PART 4: STIPULATED FACTS

THE PARTIES HEREBY STIPULATE AND AGREE TO THE FOLLOWING FACTS:

4.1 Employment

1. At the time of injury, Applicant was employed by [EMPLOYER NAME] as a [JOB TITLE].

2. The employer was insured for workers' compensation by [INSURANCE CARRIER] under Policy Number [NUMBER].

3. The employment relationship was lawful.

4.2 Injury

4. On [DATE OF INJURY], Applicant sustained injury arising out of and in the course of employment (AOE/COE).

5. The injury was to the following body parts:
   [LIST ALL STIPULATED BODY PARTS]

6. The cause of injury was:
   [DESCRIBE MECHANISM OF INJURY]

4.3 Medical Treatment

7. The Applicant received medical treatment for the industrial injury.

8. The Applicant's primary treating physician is/was: [PHYSICIAN NAME]

4.4 Temporary Disability

9. Applicant was temporarily disabled for the following period(s):

10. ☐ All temporary disability has been paid
    ☐ Additional temporary disability of $[AMOUNT] remains due

4.5 Permanent and Stationary Date

11. Applicant became permanent and stationary on [DATE], as determined by:
    ☐ Primary Treating Physician
    ☐ Qualified Medical Evaluator (QME)
    ☐ Agreed Medical Evaluator (AME)
    ☐ Agreement of the parties

4.6 Earnings

12. At the time of injury, Applicant's average weekly earnings were $[AMOUNT].

13. The permanent disability rate is $[RATE] per week.
    [// GUIDANCE: PD rates are set by state law and depend on date of injury and earnings]

PART 5: STIPULATED PERMANENT DISABILITY

5.1 Permanent Disability Rating

THE PARTIES STIPULATE TO THE FOLLOWING PERMANENT DISABILITY:

Based on the report of [PHYSICIAN NAME], [QME/AME/PTP], dated [DATE]:

Combined Permanent Disability: [___]%

5.2 Apportionment

☐ No Apportionment - The permanent disability is 100% industrial.

☐ Apportionment Applies - The permanent disability is apportioned as follows:

Industrial: [___]%
Non-Industrial (prior condition): [___]%
Non-Industrial (subsequent condition): [___]%

Basis for apportionment:
[EXPLAIN - cite medical report]

Net Industrial Permanent Disability: [___]%

5.3 Permanent Disability Benefits Calculation

Based on [___]% permanent disability:

5.4 Payment of Permanent Disability

☐ Periodic Payments
Permanent disability benefits of $[RATE] per week shall be paid every [TWO WEEKS/WEEK] beginning [DATE] and continuing until paid in full.

☐ Commuted to Lump Sum
The remaining permanent disability balance of $[AMOUNT] shall be commuted to a lump sum and paid within [NUMBER] days of approval.

Reason for commutation:
☐ Applicant needs funds for [EXPLAIN]
☐ Small balance remaining
☐ Other: [EXPLAIN]

PART 6: LIFE PENSION (IF APPLICABLE)

[// GUIDANCE: Life pension is payable for permanent disability of 70% or more in most states]

☐ Life Pension Not Applicable (PD less than 70%)

☐ Life Pension Applicable

Based on permanent disability of [___]%, Applicant is entitled to a life pension.

Life Pension Rate: $[RATE] per week

Commencement: Life pension shall commence after the permanent disability payments are completed.

Duration: Life pension shall continue for the life of the Applicant.

PART 7: FUTURE MEDICAL TREATMENT

7.1 Award of Future Medical Treatment

FUTURE MEDICAL TREATMENT SHALL REMAIN OPEN.

Applicant is entitled to receive all medical treatment reasonably required to cure or relieve the effects of the industrial injury, subject to utilization review, for the following body parts:

Awarded Body Parts for Future Medical:
[LIST ALL BODY PARTS - Should match stipulated injury]

7.2 Medical Provider Network (MPN)

☐ Treatment shall be obtained through the employer's Medical Provider Network (MPN).

☐ Treatment shall be provided by Applicant's pre-designated physician: [NAME]

☐ Applicant may select physician after the first 30 days (or as allowed by state law).

7.3 Self-Procured Treatment

If Applicant obtains treatment outside the authorized system, reimbursement shall be subject to applicable workers' compensation fee schedules and utilization review.

PART 8: SUPPLEMENTAL JOB DISPLACEMENT BENEFIT (SJDB)

[// GUIDANCE: SJDB (California) or similar vocational rehabilitation benefits vary by state]

8.1 Eligibility Determination

☐ Not Eligible - Applicant was offered regular, modified, or alternative work.

☐ Eligible - Applicant is entitled to a Supplemental Job Displacement Benefit voucher because:
- Applicant has a permanent partial disability, AND
- Employer has not offered regular, modified, or alternative work

8.2 SJDB Voucher

☐ SJDB voucher in the amount of $[AMOUNT - typically $6,000 for injuries on/after 1/1/2013] shall be issued.

☐ SJDB voucher has already been issued.

☐ SJDB is not applicable to this claim.

PART 9: OTHER BENEFITS

9.1 Additional Benefits

☐ Mileage Reimbursement: Applicant is entitled to mileage reimbursement for medical treatment at the rate established by the state.

☐ Death Benefits: Not applicable

☐ Other: [SPECIFY]

9.2 Credits

☐ Defendant is entitled to credit for benefits previously paid as itemized in Part 5.

☐ Defendant is entitled to credit against any third-party recovery.

PART 10: ATTORNEY FEES

10.1 Applicant's Attorney Fees

Attorney Fee: [___]% of permanent disability awarded

Fee Calculation:
- Permanent Disability Award: $[AMOUNT]
- Fee Percentage: [___]%
- Attorney Fee: $[FEE AMOUNT]

☐ Fee to be deducted from periodic payments
☐ Fee to be paid from lump sum commutation
☐ Defendant to pay fee directly to Applicant's attorney

10.2 Fee Approval

The parties request that the Workers' Compensation Judge approve the attorney fee as reasonable.

PART 11: LIENS

11.1 Outstanding Liens

☐ No liens are outstanding

☐ The following liens are outstanding:

11.2 Lien Disposition

☐ All liens have been resolved
☐ Liens to be addressed separately
☐ Liens to be paid from award: [SPECIFY]

PART 12: RIGHT TO REOPEN

12.1 Petition to Reopen

[// GUIDANCE: Most states allow claims to be reopened for new and further disability within a specified period - typically 5 years from date of injury]

Applicant retains the right to petition to reopen this case for new and further permanent disability within [5 YEARS - or state-specific period] from the date of injury, pursuant to [CITE STATE STATUTE].

This right is NOT waived by this stipulation.

12.2 Conditions for Reopening

A petition to reopen may be filed if:
- Applicant's condition worsens (new and further disability)
- New medical evidence becomes available
- As otherwise permitted by law

PART 13: SIGNATURES AND REQUEST FOR AWARD

13.1 Request for Award

THE PARTIES HEREBY REQUEST THAT THE WORKERS' COMPENSATION JUDGE ISSUE A FINDINGS AND AWARD CONSISTENT WITH THESE STIPULATIONS.

13.2 Applicant Signature

I have read and understand these Stipulations. I agree to all terms. I understand that future medical treatment remains open and that I may petition to reopen for new and further disability.

Signature: _________________________________

Printed Name: [NAME]

Date: [DATE]

13.3 Applicant's Attorney Signature

I have reviewed these Stipulations with my client. I recommend approval.

Signature: _________________________________

Printed Name: [NAME]

Bar Number: [NUMBER]

Date: [DATE]

13.4 Defendant's Attorney Signature

On behalf of Defendant and [INSURANCE CARRIER], I agree to these Stipulations.

Signature: _________________________________

Printed Name: [NAME]

Bar Number: [NUMBER]

Date: [DATE]

PART 14: FINDINGS AND AWARD

FOR WORKERS' COMPENSATION JUDGE USE ONLY

FINDINGS OF FACT

Based on the Stipulations of the parties, the Workers' Compensation Judge finds:

1. Applicant sustained industrial injury on [DATE] to [BODY PARTS].

2. At the time of injury, Applicant's employer was [EMPLOYER], insured by [CARRIER].

3. Applicant's average weekly earnings were $[AMOUNT].

4. Applicant became permanent and stationary on [DATE].

5. As a result of the industrial injury, Applicant sustained [___]% permanent disability.

6. [APPORTIONMENT FINDINGS IF APPLICABLE]

AWARD

IT IS HEREBY ORDERED AND AWARDED:

1. Permanent Disability: Defendant shall pay Applicant permanent disability of $[AMOUNT] at the rate of $[RATE] per week, less credit for amounts already paid.

2. Life Pension: [IF APPLICABLE] Defendant shall pay Applicant a life pension of $[RATE] per week commencing upon completion of permanent disability payments.

3. Future Medical Treatment: Applicant is entitled to future medical treatment to cure or relieve the effects of the industrial injury to [BODY PARTS], subject to utilization review.

4. Supplemental Job Displacement Benefit: [IF APPLICABLE] Defendant shall issue an SJDB voucher in the amount of $[AMOUNT].

5. Attorney Fees: Applicant's attorney is awarded a fee of $[AMOUNT] ([___]%), to be paid [METHOD].

6. Jurisdiction Reserved: Jurisdiction is reserved over issues not addressed herein.

ORDERED this [DAY] day of [MONTH], [YEAR].

Workers' Compensation Judge: _________________________________

Printed Name: Hon. [NAME]

PART 15: IMPORTANT NOTICES

For the Applicant:

1. Future Medical Treatment: You retain the right to receive medical treatment for your work injury. Contact the claims administrator to authorize treatment.

2. Right to Reopen: You may petition to reopen your case for new and further disability within [TIME PERIOD] from your date of injury if your condition worsens.

3. Keep Records: Keep copies of all medical records and correspondence related to your injury.

4. Report Address Changes: Notify the insurance carrier and WCAB of any address changes.

For the Defendant:

1. Payment Obligation: Permanent disability payments must be made timely as ordered.

2. Medical Treatment: Continue to authorize and pay for reasonable medical treatment for the awarded body parts.

3. SJDB Voucher: If applicable, issue the voucher within the required timeframe.

[END OF DOCUMENT]