Tip for Settlement Petition (state-specific)

Unlike a Compromise and Release, some settlement petitions may preserve your right to future medical treatment

Tip for Settlement Petition (state-specific)

Always have an attorney review the petition terms before signing

Tip for Settlement Petition (state-specific)

The judge will verify you understand the terms and that the settlement is fair

Workers' Compensationhard

Petition for Settlement

Settlement Petition (state-specific) · State Workers' Compensation Agencies

Formal request to the workers' comp board to approve a settlement. May cover wage loss, medical benefits, or both.

Form Details

Total fields: 42
Auto-fillable: 18 (43%)
Time without BeneFill: 45 minutes
Time with BeneFill: 14 minutes
Time saved: 31 minutes
Filled by: patient
Frequency: one time
State-specific: Yes — form may vary by state

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Where to Submit This Form

📬

File with your state's Workers' Compensation Board

Typically filed by your attorney with the appropriate workers' comp board or court.

🏢

File at the Workers' Compensation Board during a hearing

Required Attachments

📎 Settlement petition signed by all parties
📎 Medical evidence and disability rating reports
📎 Wage and benefit information
📎 Attorney fee disclosure and approval

Processing Time

Varies by state — typically 2-8 weeks for a judge to review and approve the petition.

What Happens Next

The Workers' Compensation Judge will schedule a hearing or review the petition. If approved, the settlement terms are legally binding.

Tips for This Form

✓ Unlike a Compromise and Release, some settlement petitions may preserve your right to future medical treatment
✓ Always have an attorney review the petition terms before signing
✓ The judge will verify you understand the terms and that the settlement is fair
✓ Settlement amounts should account for future medical needs, lost wages, and permanent disability

More Workers' Compensation Forms

First Report of Injury (Generic FROI)

FROI · State Workers' Compensation Agencies

Report of workplace injury or occupational disease filed with the state agency and insurer. Required within 3-10 days of injury depending on state. Establishes the claim in the system.

California Workers' Comp Claim Form

DWC-1 · California Division of Workers' Compensation

Employee claim form for workers' compensation benefits in California. Employer must provide within one working day of learning of a workplace injury or illness.

New York Employee Claim

C-3 · New York Workers' Compensation Board

Employee's claim for compensation filed with the NY Workers' Compensation Board. Must be filed within 2 years of the accident or within 2 years of when the claimant knew or should have known the condition was work-related.

Texas Employee's Claim for Compensation

DWC-041 · Texas Department of Insurance, Division of Workers' Compensation

Employee's claim for compensation for a work-related injury or illness in Texas. Must be filed within one year of injury or within one year of when the employee knew or should have known the condition was work-related.

Florida First Report of Injury or Illness

DFS-F2 · Florida Division of Workers' Compensation

Florida's first report of injury or illness form. Employer must file within 7 days of knowledge of an injury or within 24 hours if the injury results in death.

North Carolina Notice of Accident to Employer

Form 18 · North Carolina Industrial Commission

Notice of Accident to Employer and Claim of Employee. Must be filed when injured on the job in North Carolina. Written notice to employer required within 30 days; claim filed within 2 years.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Workers' Compensation Agencies or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.