Page 1 of 3KANSAS DEPARTMENT OF LABOR www.dol.ks.govSETTLEMENT AGREEMENT FINAL RECEIPT AND RELEASE OF LIABILITY KWC Form D (Rev. 1116)MAIL: Division of Workers Compensation401 SW Topeka Blvd., Suite.
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How to fill out the KS K-WC Form D online
The KS K-WC Form D is a crucial document in the Kansas Workers Compensation process, used to finalize settlements and release liability upon payment. This guide will help you fill out the form accurately and efficiently, ensuring compliance with legal requirements.
Follow the steps to complete the KS K-WC Form D online
- Click the ‘Get Form’ button to access the KS K-WC Form D and open it for editing.
- In the first section, provide the employer's name and address, ensuring all details are accurate and complete.
- Enter the insurance carrier's information, including the phone number and address, as well as the insurance company file number.
- Record the injured worker's details, including their full name, Social Security number, and address.
- Specify the nature of the injury or disease for which the compensation claim is being made.
- Indicate the date of injury or onset of the disease.
- Provide the last day the employee worked and the date they were able to return to work.
- If applicable, fill in any dates the employee worked between the injury date and the last date of disability.
- Complete the average weekly wage and weekly compensation rate fields.
- Fill out the compensation paid on the basis of temporary disability and provide details for any permanent partial disability.
- Document any hospital and medical expenses related to the claim.
- In the final section, ensure that the receipt and release of liability is accurately signed and dated by both the employer and the worker.
- Verify that the document is notarized as required, then save your changes, and choose to download, print, or share the completed form.
Complete your KS K-WC Form D online today for a smooth claims process.
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