NOTICE OF THIRD-PARTY SETTLEMENT AND CONSENT REQUEST

(Workers' Compensation - Settlement with Third Party Tortfeasor)

PART 1: NOTICE INFORMATION

DATE OF NOTICE: [DATE]

FROM:
[INJURED WORKER NAME]
[ADDRESS]
[PHONE]
[EMAIL]

AND/OR:

[INJURED WORKER'S ATTORNEY NAME]
[FIRM NAME]
[ADDRESS]
[PHONE]
[EMAIL]

TO:
[INSURANCE CARRIER / EMPLOYER NAME]
[ATTENTION: SUBROGATION DEPARTMENT]
[ADDRESS]

RE: Notice of Proposed Third-Party Settlement

PART 2: CLAIM INFORMATION

2.1 Workers' Compensation Claim

Injured Worker: [NAME]

Date of Injury: [DATE]

Workers' Compensation Claim Number: [NUMBER]

Employer: [EMPLOYER NAME]

Insurance Carrier: [CARRIER NAME]

Body Parts Injured: [LIST]

2.2 Third-Party Case

Third Party Defendant: [NAME]

Third Party's Insurance Carrier: [CARRIER NAME]

Third Party Case Number (if litigation filed): [NUMBER]

Court (if applicable): [COURT NAME]

PART 3: DESCRIPTION OF THIRD-PARTY LIABILITY

3.1 Incident Description

[DESCRIBE THE INCIDENT AND HOW THE THIRD PARTY CAUSED THE INJURY]

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

3.2 Third Party's Alleged Liability

[DESCRIBE THE BASIS FOR THIRD PARTY'S LIABILITY]

☐ Motor vehicle accident - Third party driver at fault
☐ Product liability - Defective product
☐ Premises liability - Dangerous condition
☐ Professional negligence
☐ Intentional tort
☐ Other: [SPECIFY]

3.3 Disputed Issues (if any)

[DESCRIBE ANY LIABILITY OR DAMAGES DISPUTES]

____________________________________________________________________________

____________________________________________________________________________

PART 4: PROPOSED SETTLEMENT TERMS

4.1 Settlement Amount

Gross Settlement Amount: $[AMOUNT]

Settlement Offered By: [THIRD PARTY / THIRD PARTY'S INSURER]

4.2 Settlement Structure

☐ Lump Sum Payment
Amount: $[AMOUNT]

☐ Structured Settlement
[DESCRIBE PAYMENT STRUCTURE]

☐ Combination
[DESCRIBE]

4.3 Releases

The proposed settlement requires execution of:

☐ General release of all claims against the third party
☐ Limited release for specific claims: [DESCRIBE]
☐ Release of claims against additional parties: [LIST]

PART 5: PROPOSED ALLOCATION OF SETTLEMENT

5.1 Gross Settlement Breakdown

5.2 Employer/Carrier Lien Details

Current Lien Amount (as stated by Carrier): $[AMOUNT]

Breakdown of Lien:

5.3 Proposed Lien Resolution

Injured Worker proposes to resolve the lien as follows:

☐ Full Payment of Lien: $[AMOUNT]

☐ Reduced Lien Payment: $[AMOUNT]
Reason for reduction:
☐ Employer/Carrier share of attorney fees ([___]%)
☐ Employer comparative fault
☐ Negotiated reduction
☐ Other: [EXPLAIN]

☐ Waiver of Credit Against Future Benefits: ☐ Requested ☐ Not Requested

PART 6: ATTORNEY FEE CONTRIBUTION

6.1 Attorney Fee Calculation

Total Attorney Fee: $[AMOUNT] ([___]% of $[GROSS])

Carrier's Proportionate Share:

Carrier's recovery / Total recovery = [___]%

Carrier's fee contribution: [___]% x $[ATTORNEY FEE] = $[AMOUNT]

6.2 Proposed Fee Allocation

PART 7: CONSENT REQUEST

7.1 Request for Consent

Pursuant to [CITE STATE STATUTE], Injured Worker hereby requests written consent from Employer/Carrier to settle the third-party claim on the terms described above.

7.2 Response Deadline

Please respond to this request by: [DATE - typically 15-30 days]

7.3 Form of Response

Please indicate your response by completing the attached Consent Form (Part 11) and returning it to:

[ATTORNEY NAME]
[ADDRESS]
[FAX]
[EMAIL]

PART 8: SUPPORTING DOCUMENTATION

8.1 Documents Enclosed

☐ Copy of proposed Release and Settlement Agreement
☐ Itemized litigation costs
☐ Attorney fee agreement
☐ Medical records summary
☐ Demand letter and response
☐ Expert reports (if any)
☐ Other: [SPECIFY]

8.2 Documents Available Upon Request

☐ Complete litigation file
☐ Deposition transcripts
☐ Expert reports
☐ Discovery responses
☐ Other: [SPECIFY]

PART 9: REASONS FOR SETTLEMENT

9.1 Rationale for Settlement

[EXPLAIN WHY THE PROPOSED SETTLEMENT IS REASONABLE]

Factors considered:

☐ Liability risks: [EXPLAIN]
☐ Damages uncertainties: [EXPLAIN]
☐ Third party's insurance limits: $[AMOUNT]
☐ Comparative fault issues: [EXPLAIN]
☐ Cost of continued litigation: [ESTIMATE]
☐ Time to trial: [ESTIMATE]
☐ Health/financial needs of injured worker: [EXPLAIN]
☐ Other: [EXPLAIN]

9.2 Assessment of Recovery Value

If case went to trial:

PART 10: EFFECT ON WORKERS' COMPENSATION CLAIM

10.1 Credit Against Future Benefits

Under [STATE] law:

After payment of the lien, Employer/Carrier is entitled to a credit against future workers' compensation benefits equal to:

☐ The injured worker's net recovery (after fees and costs)
☐ Other calculation: [SPECIFY STATE FORMULA]

Estimated Credit Amount: $[AMOUNT]

10.2 Continuing WC Benefits

Current Workers' Compensation Status:

☐ Claim is open - Future medical treatment ongoing
☐ Claim is open - Temporary disability ongoing
☐ Claim is settled
☐ Other: [SPECIFY]

Effect of Third-Party Settlement on WC Claim:

[EXPLAIN HOW THE SETTLEMENT WILL AFFECT THE WC CLAIM]

PART 11: EMPLOYER/CARRIER CONSENT FORM

[TO BE COMPLETED BY EMPLOYER/CARRIER]

CONSENT TO THIRD-PARTY SETTLEMENT

RE: [INJURED WORKER NAME]
WC Claim Number: [NUMBER]
Date of Injury: [DATE]

☐ CONSENT GRANTED

[EMPLOYER/CARRIER NAME] hereby consents to the proposed third-party settlement on the terms set forth in this Notice, subject to the following conditions:

1. Payment of lien in the amount of: $[AMOUNT]
2. Payment of carrier's share of attorney fees: $[AMOUNT]
3. Total payment to Employer/Carrier: $[AMOUNT]
4. Credit against future benefits in the amount of: $[AMOUNT]
5. Other conditions: [SPECIFY]

☐ CONSENT CONDITIONALLY GRANTED

Consent is granted subject to the following modifications:

____________________________________________________________________________

____________________________________________________________________________

☐ CONSENT DENIED

Consent is denied for the following reasons:

____________________________________________________________________________

____________________________________________________________________________

☐ ADDITIONAL INFORMATION REQUESTED

Before responding, Employer/Carrier requests the following additional information:

____________________________________________________________________________

____________________________________________________________________________

Authorized Signature: _________________________________

Printed Name: [NAME]

Title: [TITLE]

Company: [EMPLOYER/CARRIER NAME]

Date: [DATE]

Phone: [PHONE]

Email: [EMAIL]

PART 12: VERIFICATION

Injured Worker Verification

I, [INJURED WORKER NAME], declare under penalty of perjury that:

☐ The information contained in this Notice is true and correct to the best of my knowledge.

☐ I have been advised by my attorney regarding the terms and consequences of this settlement.

☐ I understand that Employer/Carrier consent is required before finalizing this settlement.

☐ I understand the effect this settlement may have on my workers' compensation benefits.

Injured Worker Signature: _________________________________

Date: [DATE]

Attorney Verification

I, [ATTORNEY NAME], certify that:

☐ I represent [INJURED WORKER NAME] in the third-party claim described herein.

☐ I have explained the terms of the proposed settlement and its effect on workers' compensation benefits to my client.

☐ The proposed allocation of settlement proceeds complies with applicable law.

Attorney Signature: _________________________________

State Bar Number: [NUMBER]

Date: [DATE]

[END OF DOCUMENT]