Use this as a private worksheet
Slow down and identify exactly what rights, benefits, and medical issues the agreement addresses. This is not an official agency or court form.
Settlement terms
- ☐ Gross amount: ______________________________
- ☐ Attorney fee/cost: ______________________________
- ☐ Medical rights open/closed: ______________________________
- ☐ Wage/disability rights released: ______________________________
- ☐ Resignation language if any: ______________________________
Unresolved issues
- ☐ Future treatment: ______________________________
- ☐ Liens/offsets: ______________________________
- ☐ Permanent restrictions: ______________________________
- ☐ Return-to-work status: ______________________________
- ☐ Other claims: ______________________________
Privacy reminder
Keep sensitive medical, wage, claim-number, and employment information private. Share it only with appropriate official agencies, licensed professionals, insurers, treating providers, or other people who legitimately need it for the claim.