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Division of Workers' Compensation

   
Settlement Documents
   

Form

Description

Settlement Agreement - Represented Claimant

Form # WC104

Fillable  pdf MS Word
This is the standard settlement agreement for represented claimants required by the Division. See Rule 7-2, Content and Approval of Settlement Agreements
   

Settlement Agreement - Pro Se

(Unrepresented) Claimant

Form # WC103

Fillable  pdf MS Word
 
This is the standard settlement agreement for unrepresented claimants required by the Division. See Rule 7-2, Content and Approval of Settlement Agreements
   

Settlement Routing Sheet

Form # WC105

Fillable  pdf MS Word
This is a checklist used by attorneys.  It accompanies settlement documents and is required by the Division to ensure all required information is included.
   

Settlement Order -

Represented Claimant

Form # WC73

Fillable  pdf MS Word
This is the standard Settlement Order submitted to the Director or Administrative Law Judge for settlement approval on represented claimants.
   

Settlement Order - Pro Se

Unrepresented Claimant

Form # WC102

Fillable  pdf MS Word
This is the standard Settlement Order submitted to the Director or Administrative Law Judge for settlement approval on unrepresented claimants.
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