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(a)  The party submitting the stipulation shall:

(1)  file the original with a copy for each party to the agreement; if filing electronically, file one original and no copies.

(2)  at the top page of each stipulation list the names, addresses, and telephone numbers of all parties to the agreement, the ICMS Board claim number(s) of the employee, the dates of accident covered by the agreement where a Board file has been created by a Form WC-1 or Form WC-14, the names and addresses of all attorneys with a designation of which parties they represent, and the Federal tax identification number of the employee’s attorney.  For dates of accident where a Board file has not been created but covered by the stipulation, such dates of accident shall only be listed in the body of the agreement;

(3)  submit 9 1/2 x 12 ½ envelopes addressed to each party to the agreement; if filing electronically, do not submit envelopes.

(4)  attach a copy of the Form WC-1 for each date of accident covered by the settlement;

(5)  attach a copy of the fee contract of counsel for the employee/claimant; and,

(6)  attach the most recent medical report or summary which describes the medical condition of the employee, including a very brief statement of the surgical history, if any, if that history is not already specified within the stipulation.  The entire medical record should NOT be attached.

(7)  when submitting a stipulation for approval by electronic mail, the stipulation must be submitted separately from supporting documentation.

(8)  approval of a stipulation may be sent by electronic mail to the parties and attorneys of record.  Whenever electronic transmission is not available, approval will be sent by mail.

(9)  for all stipulations, at the top of the first page of the stipulation, the first five inches shall be left blank for the approval stamp;

(10)  All stipulations shall be limited to no more than 25 pages, including supporting documents, unless prior approval is given by the Board or the Settlement Division.

(b)  A stipulation which provides for liability of the employer or insurer shall:

(1)  state the legal and/or factual matters about which the parties disagree; and,

(2)  state that all incurred medical expenses which were reasonable and necessary have been or will be paid by the employer/insurer.  If the parties have agreed for medical treatment to be provided for a specific period in the future, then the stipulation must so state, and must further specify whether the agreement is limited to certain specific providers, and whether those providers may refer to others if needed.  Furthermore, the stipulation shall provide that the parties will petition the Board for a change of physician in the event that a specifically named physician is unable to render services, and the parties cannot agree.  If the stipulation does not contain a provision that medical expenses may be incurred for a specific period in the future after the approval of the stipulation, then the stipulation must contain a statement which explains why that provision is not necessary.

(c)  The insurer shall certify that it has complied with O.C.G.A. § 34-9-15

by having sent a copy of the proposed settlement to the employer prior to any party having signed it.

(d)  If the agreement provides for a structured settlement to be paid by a party other than the employer or the insurer, then the stipulation must contain a provision that the employer and insurer will be liable for the agreement in the event of the default or failure of that third party to pay.  In addition, if the stipulated settlement agreement provides for a Medicare Set-Aside (MSA), the stipulated settlement agreement shall contain a provision as to the actual cost of the MSA.

(e)  Unless otherwise specified in the attorney fee contract filed with the Board and in the terms of the stipulation, the proceeds of the approved stipulated settlement agreement shall be sent directly to the employee or claimant.  If an attorney is to be paid, the stipulation must state the amount of the fee, and itemize all expenses which should be reimbursed. Further, an attorney shall not receive an attorney’s fee as a portion or percentage of any medical treatment or expenses, or any money designated for medical treatment or expenses.  Expenses and attorney fees shall be paid in a check payable to the attorney only, and proceeds due to the employee shall be paid in a check payable to the employee only and the attorney shall certify that the expenses comply with Rule 1.8(e) of the Georgia Rules of Professional Responsibility and Board Rule 108.

(f)  A Form WC-1 shall be filed with every no-liability stipulation for each date of accident covered in that stipulation.  In all no-liability settlements where the claimant is represented by counsel, the attorney must submit a Form WC-15 certifying that any fee charged is fair and reasonable and does not exceed twenty five percent as allowed under the provisions of O.C.G.A. § 34-9-108 and Board Rule 108.

(g)  Stipulations which contain waivers or releases of causes of action over which the Board has no jurisdiction will not be approved by the Board.

(h)  The Board may hear evidence or make informal inquiry regarding any settlement.

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