24.29.1202 DOCUMENTATION REQUIREMENTS
(1) A petition to the department for lump-sum conversion of biweekly permanent total disability benefits for all dates of injury must include a description of the lump-sum proposal, including but not limited to:
(a) analysis of current financial conditions as described in (3);
(b) analysis of financial condition under the proposed lump-sum conversion, that includes a description of the use of the lump-sum and how this use will contribute to financially sustaining the worker over the same period biweekly payments would have been paid;
(c) analysis of financial condition that would be reasonably expected had the worker not been injured as described in (6); and
(d) an affidavit signed by the worker attesting to the validity of information provided in the written petition.
(2) A petition to the department for conversion of biweekly permanent partial disability benefits to a lump-sum payment must include an analysis of current financial conditions as described in (3) only for a claim with a date of injury prior to July 1, 1991.
(3) "Analysis of current financial condition" for purposes of (1) shall include a list of all the worker's income, assets, and liabilities, as well as other available resources, including but not limited to:
(a) periodic income (specify periods reported):
(i) social security disability income,
(ii) social security retirement income,
(iii) retirement or pension income,
(iv) other disability insurance,
(v) health insurance benefits,
(vi) mortgage insurance benefits,
(vii) spousal or other family income,
(viii) life insurance proceeds,
(ix) credit disability benefits,
(x) interest or dividend income,
(xi) workers' compensation benefits,
(xii) third party recovery (actual or potential);
(b) monetary assets:
(i) cash on hand,
(ii) checking account,
(iii) savings account,
(iv) accounts and notes receivable,
(v) savings bonds,
(vi) stocks and bonds,
(vii) mutual funds,
(viii) cash value of life insurance,
(ix) cash value of annuities,
(x) cash value of retirement fund;
(c) fixed assets:
(i) home and property,
(ii) other real estate,
(iii) retirement fund,
(iv) motor vehicles,
(v) personal property;
(i) all monthly living expenses,
(ii) existing delinquent or outstanding debts,
(iii) periodic payments on debts,
(iv) long-term liabilities,
(v) attorney fees and costs.
(4) If a petition for lump-sum conversion of permanent total benefits involves the partial or total elimination of existing delinquent or outstanding debts, a debt management plan must be described and include:
(a) plan of management, through applying the proposed lump-sum payment, of all existing delinquent or outstanding debts, both short- and long-term; and
(b) description of how the worker will be sustained financially through use of the lump-sum payment and other available resources, including cash available throughout the life of the debt management plan, to manage delinquent or outstanding debts.
(5) If a permanent total benefit lump-sum proposal involves a business venture, a business plan must be described and include:
(a) Information indicating the worker's capability in proposed business venture, including:
(i) relevant educational and work history,
(ii) knowledge of the proposed business,
(iii) if managerial, managerial capability,
(iv) role to be assumed in the proposed business.
(b) If the venture is a new business, information about the proposed business venture including, but not limited to:
(i) description of the proposed business venture,
(ii) estimate of the purchase price of the business,
(iii) work sheets showing: total source of dollars, start-up costs, projected expenses and net income forecast,
(iv) feasibility study of the market conditions in the intended market area, showing that the business is a feasible venture.
(c) If the venture is an existing business, information about the proposed business including, but not limited to:
(i) description of proposed business venture,
(ii) legal agreement showing intent to sell the existing business, purchase price of the business, and any conditions placed upon such sale,
(iii) income tax statements and balance sheets for the two consecutive years prior to the agreement to sell the business,
(iv) work sheets showing total source of dollars, start-up costs, projected expenses and net income forecast,
(v) market analysis showing market conditions in the intended market area.
(d) A statement of cash that will be available to the worker as income on a biweekly basis after start-up costs and other business expenses are considered throughout the life of the venture.
(6) "Analysis of financial condition that would be reasonably expected had the worker not been injured" for purposes of (1) must include a description of the income the worker would have received and the basis upon which the estimate is derived. The analysis must include:
(a) evidence of education and work experience, including:
(i) work history, dates and descriptions of employment or unemployment, names and locations of employers;
(ii) highest level of formal education attained, degrees received, dates of attendance, names and locations of schools; and
(iii) special training, professional licenses, registrations, or certifications, certifications received; dates of attendance, names and locations of institutions providing training, licenses, registrations or certifications.
(b) evidence of probable job promotions and pay increases, including:
(i) supportive documentation from employers, union contracts, or other reasonable substantiation of probable job promotions,
(ii) wage history,
(iii) statement from employer at the date of the accident of last wage rate paid; and
(iv) supportive documentation estimating wage rates from the date of the accident up to age 65.
(7) A request for lump-sum settlement of medical benefits must include the following information:
(a) copy of medical reports documenting maximum medical improvement, current diagnosis, and recommendations for future treatment, if any;
(b) specific dollar amount of the settlement allocated to medical benefits;
(c) statement from the claimant and insurer as to why it is in the best interest of the parties to settle medical benefits;
(d) statement signed by the claimant to acknowledge the claimant understands which specific medical benefits will terminate upon settlement;
(e) statement signed by the claimant to acknowledge the claimant is on notice and understands that the future medical benefits settled under the agreement may not be covered by secondary healthcare payers such as Medicare, Medicaid, or other health insurers; and
(f) submission of the following completed forms to the department:
(i) "Summary of Settlement of Medical Benefits" form with original signatures by the claimant and the insurer or the insurer's authorized representative; and
(ii) "Petition for Settlement Injury/Occupational Disease Medical Benefits Closed On An Accepted Claim" form with original signatures by the claimant, a witness, and the insurer or the insurer's authorized representative.
(8) The total value of the workers' compensation benefits may be discounted at the current rate established by the department when an insurer calculates a conversion to a lump-sum payment. Only for claims with dates of injury between April 15, 1985 and June 30, 1987, the lump-sum payment may be discounted by 7%, compounded annually.