Document x1BYOB3QnVbKOzw2dE5jGGGK1
2. EMPLOYER FILE NUMBER:
3. EMPLOYER'S UNEMPLOYMENT INSURANCE ACCOUNT NUMBER (UIAN):
6. EMPLOYER NAME:
Sherwin-Williams Co.
7. EMPLOYER ADDRESS:
101 Prospect Avenue Cleveland, OH 44115-1075
8. INSURER:
Travelers Insurance Co.
COMMUTATION OF BENEFITS OR
COMPROMISE SETTLEMENT
STATE OF MAINE WORKERS' COMPENSATION BOARD STATION 27 AUGUSTA, MAINE 04333
9. EMPLOYEE NAME:
10. EMPLOYEE AODRESS:
5. EMPLOYEE'S SOCIAL SECURITY NUMBER:
REDACTED
11. DATE OF INJURY: 12. DESCRIPTION OF INJURY:
1/29/90
respiratory distress
13. COMMUTATION
14.
COMPROMISE HI
TYPE OF SETTLEMENT: IF COMMUTATION, FORM WCB 10A IS REQUIRED
IF COMPROMISE, SEE REVERSE FOR INSTRUCTIONS.
SUMMARY OF BENEFITS PAID TO DATE FOR THIS INJURY OR DEATH:
PHYSICIAN HOSPITAL OTHER MEDICAL WEEKLY COMPENSATION PERMANENT IMPAIRMENT REHABILITATION
15.
$
${* 1,187.62
$ 98,463.99
$ $
DEATH BENEFIT
$
FUNERAL
$
LEGAL (EMPLOYEE RELATED)
$
LEGAL (EMPLOYER RELATED)
$
OTHER
$
TOTAL PAID $ 99,651.61
SUMMARY OF PROPOSED COMMUTATION:
PHYSICIAN
PERMANENT IMPAIRMENT
HOSPITAL
REHABILITATION
OTHER MEDICAL
DEATH BENEFIT
WEEKLY COMPENSATION
OTHER
$
"ft 4/WO.DQ .jfoytbtc
,, ,,
16. PREPARER'S NAME AND TITLE (TYPE OR PRINT):
I, , . TOTAL PROPOSED SETTLEMENT $ 50, 000.00
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SIGNATURE (FORM MUST BE SIGNED):
DATE:
|
Sheilah R. McLaughlin Attorney for Emolover/Insu
%jbJkJL ^
RELEASE
. IQjCf/-9_4__________
17. EMPLOYEBDEPENDENT:
I AM THE PERSON ENTITLED TO WORKERS' COMPENSATION BENEFITS ON ACCOUNT OF THIS INJURY OR DEATH. I HAVE READ THIS WORKSHEET AND
ALL ATTACHMENTS. WHEN I RECEIVE THE AMOUNT SHOWN ABOVE AND THIS SETTLEMENT IS APPROVED BY THE HEARING OFFICER, I RELEASE THE
EMPLOYER AND INSURER NAMED ABOVE FROM ALL FURTHER LIABILITY FOR THIS INJURY. I CONSENT TO THE SETTLEMENT.
SIGNATURE EMPLOYEBDEPENDENT
---'SIGNATURE ATTORNEY
' L / O' '-/
DATE
EMPLOYER/INSURER: THE EMPLOYER/INSURER CONSENTS TO THE SETTLEMENT:
YES \~P(m | j
j
L
1------1 1------ 1 SIGNATURE EMPLOYER/INSURER
DECISION
18. THE REQUESTED SETTLEMENT (lS/ISJKW) APPROVED. THE EMPLOYER/INSURER IS ORDERED TO PAY THE EMPLOYEE/DEPENDENT THE SUM OF $ ----------------------------------------------- (CIRCLE ONE) IN A LUMP SUM SETTLEMENT ACCORDING TO THE WORKERS' COMPENSATION ACT. THE EMPLOYER/INSURER IS ORDERED TO PAY ALL OUTSTANDING COMPENSATION OBLIGATIONS
INCURRED PRIOR TO THIS SETTLEMENT BY THE EMPLOYEE/DEPENDENT. THE EMPLOYER/INSURER IS ORDERED TO PAY THE ATTORNEY OF THE EMPLOYEE/DEPENOENT A FEE OF
*\
ns-: ALL PENDING PETITIONS BASED ON THIS CLAIM ARE HEREBY DISMISSED.
HEARING OFFICER'S SIGNATURE
DATE