INFORMATION GUIDELINES FOR SUBMISSION OF SETTLEMENT DOCUMENTS
Your assistance in complying with these guidelines and careful preparation of settlement
documents can prevent unnecessary delay.
All Settlements (Both C&Rs and Stipulations)
Complete all blank spaces on the form with specific information (including signatures
and WCAB No. if applicable). State all amounts and periods paid. The caption
should state the name of the defendant against whom the award is to be made.
File all medical reports, including those of treating physicians. Reports should be
originals and arranged in reverse chronological order.
Medical reports used as the basis of settlement should fully address all issues.
Fully explain the basis for the settlement amount, including how PD was determined, and
file copies of all ratings (DEU, private, or self-rating, if any).
For injuries on or after 1/1/94, a PD report from the treating physician or evidence of
good faith efforts to obtain such a report is required.
If the injured worker is unrepresented, and the case is settled on the treating physician’s
report, include documentation that the injured worker was advised of his/her right to a
QME at defendant’s expense (LC 4061, LC 4062) (restricted to injuries on or after
If TD or PD is payable at less than maximum, file all documents needed to determine
applicable wage, if applicant is not represented. If applicant is represented provide an
All lien claims must be addressed. State good faith efforts made regarding unresolved
Body parts included in this settlement shall be specifically stated. Do not refer to “all
body parts” as listed in medical records or reports. (See SCIF v. WCAB (Bias), 43 CCC
Claims for overpayment must be fully disclosed and the basis for the overpayment
Provide the WCAB with proof of service on all parties, including lien claimants.
Where the injured w