of a Statutory Accident Benefits Claim
(For accidents between June 22, 1990 and December 31, 1993)
NOTICE AND CAUTION
Your insurer is required to give you this SETTLEMENT DISCLOSURE NOTICE if you have
both agreed on a cash settlement that will permanently end your entitlement to one or
more accident benefits. This SETTLEMENT DISCLOSURE NOTICE must be completed
and signed by your insurer. Your insurer will probably also give you a Release to sign.
YOU SHOULD CONSIDER SEEKING LEGAL, FINANCIAL AND MEDICAL ADVICE
BEFORE YOU SIGN A RELEASE.
IF YOU SIGN THIS SETTLEMENT DISCLOSURE NOTICE AND A RELEASE, YOU
WILL BE GIVING UP RIGHTS YOU MAY HAVE NOW OR IN FUTURE, EVEN IF
YOUR CONDITION CHANGES.
IF YOU CHOOSE NOT TO SIGN, YOUR BENEFITS WILL NOT BE AFFECTED OR
IF YOU DO SIGN THIS NOTICE AND A RELEASE YOU HAVE 2 BUSINESS DAYS
TO CHANGE YOUR MIND.
YOU HAVE THE RIGHT TO SEE ANY MEDICAL INFORMATION RELATING TO
YOUR CLAIM IN YOUR INSURER’S FILE AND TO OBTAIN A COPY AT THE
INSURER’S EXPENSE. IF YOU WANT TO SEE THIS INFORMATION, ASK YOUR
INSURER FOR A COPY.
PLEASE READ THIS ENTIRE DOCUMENT CAREFULLY
Form SDN-68 (02/02)
Page 1 0f 6
Provide any other details:
INSURER’S OFFER TO SETTLE BENEFITS
OFFER TO SETTLE WEEKLY INCOME BENEFITS
You have been offered $ ______________ for all past and future weekly income benefits.
OFFER TO SETTLE WEEKLY BENEFITS IF NO INCOME
You have been offered $ _____________ for all past and future weekly benefits if no
OFFER TO SETTLE SUPPLEMENTARY MEDICAL AND REHABILITATION BENEFITS
You have been offered $ _____________ for all past and future supplementary medical
and rehabilitation benefits.
OFFER TO SETTLE CARE BENEFITS
You have been offered $ _____________ for all past and future care benefits.
OFFER TO SETTLE BENEFITS FOR DAMAGE TO CLOTHING, GLASSES, HEARING
AIDS AND OTHER DEVICES
You have been offered $ ___________ for all past and future damage to clothing, glasses,