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A waiver agreement ends the right of an injured worker to ongoing and future benefits in exchange for a lump sum payment or an annuity. I apply for all insurance benefits for which I am eligible under Title II (Federal Old-Age,.Commonwealth and this settlement shall redeem liability for the payment of medical benefits and vocational rehabilitation benefits with respect to such injury. If there's more than one date of injury and it does not involve a recurrence, a separate lump sum settlement proposal must be completed and submitted. 3. This form allows the injured worker to elect a lump sum payment of the permanent partial disability award. When should this form be completed? Sign and have the completed form notarized (page 3);. Do not complete blocks 7 through 12 for a Compensatory Time Payment. I understand that if I receive a lump sum payment, I will not be entitled to supplemental income benefits for this claim. Sign and have the completed form notarized (page 3);. 4.