Appendix 5A - Defendants' Settlement Summary

DEFENDANTS’ SETTLEMENT SUMMARY IC #

1. Average Weekly Wage $ 2. Past Medical Total Paid $ 3. Past Indemnity Balance or TTD From Thru wks days @rate/wk $ Conceded/Owed $ Paid Overpymt (O-P) TPD From Thru wks days $ Conceded/Owed $ Paid Balance or O-P PPI % Level wks days @rate/wk $ Conceded/Owed $ Paid Balance or O-P Other (Description: ) $ Amt From Thru wks days @rate/wk $ Conceded/ Owed $ Paid Balance or O-P Grand Total $ Conceded $ Paid Balance or O-P 4. Net overpayment waived: $ 5. Handling of Underpayment: a. Underpayment subsumed in settlement consideration: $ b. Underpayment to be paid per settlement: $ 6. Consideration, exclusive of any underpayment identified in 5(b), above, to be paid in LSS, in addition to amounts previously paid to resolve disputed issues: $ 7. Amount payable by surety upon approval of LSS: $ 8. Pro se phone number: 9. If right to future medical is resolved by settlement, have you considered Medicare’s interest as a secondary payor? See, 42 U.S.C. § 1395y(b)(2). No Yes 10. Additional explanation (Subrogation? Annuity? Etc.): Appendix 5A