Laserfiche WebLink
Acknowledgements <br /> 1. Allowance Order(s): The Parties acknowledge, agree and understand this agreement does <br /> not set aside or reverse any allowance orders. <br /> 2. No Other Fund Impacted: The Parties represent this agreement does not subject any <br /> Department funds covered under RCW Title 51 to any responsibility or burden without <br /> prior approval from the director or designee. <br /> 3. Neither the Department of Labor and Industries nor any state fund employer is part of <br /> this Claims Resolution Settlement. No other employer is subject to any responsibility or <br /> burden under this claim. <br /> 4. Claimant has never been part of a claims resolution settlement before the Board of <br /> Industrial Insurance Appeals. <br /> 5. Claim No. SK36496 is currently open at the Department of Labor & Industries and is <br /> being administered by the Self Insured Employer, and there are no pending protests or <br /> appeals at the Department or at the Board level. The SK36496 claim will be closed without <br /> any permanent partial disability as part of this agreement. All other claims are currently <br /> closed with no pending protests or appeals at the Department or Board level, nor are there <br /> any pending applications to reopen any of the closed claims outlined herein. <br /> 2. Criteria to Settle the Impacted Claim <br /> The parties agree the following information is true and correct. <br /> Claimant Criteria to Settle <br /> Date of Birth and September 28, 1966 <br /> Age of Claimant Claimant is 55 years of aoe. <br /> Gender Male <br /> Life Expectancy of Pursuant to the tables provided by the Social Security <br /> Claimant Administration, the Claimant is expected to live an <br /> additional 27 years. <br /> (27 x 12 months =324 months) <br /> (27 x 52 weeks = 1404 weeks) <br /> Marital Status Married <br /> Dependents 0 <br /> Other Benefits None <br /> Chris Guhtarte Page 2 of 14 <br />