Amount Amount of compensation or death benefits received to date, $ due under award or agreement $- . Time compensation is to be paid under award or agreement Date of first payment (months) (weeks) (month) (years). In Case of Death Benefits, Answer the Following: What relation do you bear to deceased? — - If widow, have you remarried? What children receiving benefits have reached age of 18 Have any of dependents died? What do you intend to do with the money if a lump sum is granted? If an investment is contemplated, give details. years? Wherefore, your petitioner respectfully prays the Commission for a settlement in one lump sum, the balance due under said award or agreement said sum to be computed according to the terms of the Workmen's Compensation Law. by (name of an injured employé (or a dependent or dependents of a deceased employé) hereby petitions your Honorable Board to commute the future installments of compensation which are payable to employer, or State Workmen's Insurance Fund) under Compensation Agreement No. (or the award in claim petition No. — -) as provided in of the Workmen's Compensation Act, and to order the said (name of employer, or State Insurance Fund) to forthwith pay the section present value of such installments in one lump sum payment, and alleges the following facts as the ground of this petition. PETITION FOR TERMINATION OR MODIFICATION OF AGREEMENT OR AWARD ON GROUND OF CHANGED DISABILITY an employer (or an employé), a party to Compensation Agreement No. (or Award Claim Petition No. -), hereby petition your Honorable Board to terminate (or modify) the said agreement (or award), and as ground for the petition allege that the disability of entitled to compensation under the said agreement (or award) has terminated (or increased or decreased) as follows: (State manner in which disability has terminated or the manner in which and the extent to which it has increased or decreased.) And in support thereof I state the following facts: being first duly sworn, deposes and says that on the day of A. D. 19—, I read the above receipt to who signed the same, and that before he signed I correctly interpreted the contents of said receipt from the English language into the language to said said said receipt. and the then stated that he fully knew and understood the contents of Subscribed and sworn to before me this (Seal.) day of A. D. 19-. Notary Public in and for County and State Aforesaid. RECEIPT SHOWING RELEASE AND FINAL SETTLEMENT Release and Final Receipt for Compensation Paid Under the Workmen's Compensation Laze the sum of dollars ($ Received of -) making in all, with the weekly payments already received by me, the total sum of dollars ($) such payment being the final payment of compensation under the Workmen's Compensation Law and in consideration of which I hereby release and forever discharge the said heirs, successors and assigns, from any and all actions, causes of action, claims and demands, for, upon or by reason of any damage, loss, injury, suffering and disfigurement which heretofore has been or which hereafter may be sustained by me in consequence of an accident suffered by me on or about the day (Seal) day of being first duly sworn, deposes and says that on the 19, he read the above receipt to —, who signed the same, and that before signing, he, this deponent, correctly interpreted the contents of said receipt from the English language in the and the said derstood the contents of said receipt. language to said then stated to this deponent that he fully knew and un (statute) this will give you notice that I (e) have provided for payment to our injured employés under the above act by ins As required by ing with the Date Insurance Co. of (insert address of company here. NOTICE THAT AN Employer has CEASED TO BE A SUBSCRIBER This is to give you notice that I (we) have ceased to be a subscriber in insurance company, under by me expired (statute) and that the policy formerly be. (or is to expire ——————). TABLE OF CASES CITED Opinions of Attorney Generals of various states will be found in this table under the name of the state. Opinions of Comptroller of Treasury will be found under "Federal Act" in this table. Opinions of Special Counsel to Iowa Industrial Commission will be found in this table under "Iowa." Report of Nevada Industrial Commission will be found in this table under "Nevada." First Annual Reports Oregon Industrial Accident Commission will be found in this table under "Oregon." Rulings of Washington Industrial Accident Insurance Commission will be found in this table under "Washington." A Page 575 Aberdeen Steam Trawling & Fishing Co. v. Gill, 1 B. W. C. C. 274...... 172 653, 728, 750, 761, 763 Acres v. Frederick & Nelson, 79 Wash. 402, 140 Pac. 370, 5 N. C. C. A. 557 737 .198, 439, 618, 677, 767 Acrey v. Holtville, 2 Cal. I. A. C. Dec. 587... v. Acme White Lead & Color Works, Op. Mich. Indus. Acc. Bd. 31.... v. Thompson, 5 B. W. C. C. 19, C. A. 73 28 281 245 Addie & Sons' Collieries v. Trainer, 7 F. 115, Ct. of Sess... Adler, In re, Op. Sol. Dept. of L. 63, 67, 15 Comp. Dec. 845...... .188, 811 v. Thomas Hefsky Theatre Co., The Bulletin, N. Y., vol. 1, No. 11, p. 13 ... Admiral Fishing Co. v. Robinson, 3 B. W. C. C. 247, C. A. Agard, In re, Op. Sol. Dept. of L. 550..... ...335, 805 171 250 .118, 182 199 Agler v. Michigan Agriculture College, 181 Mich. 559, 148 N. W. 341, 5 v. Michigan Agriculture College, Op. Mich. Indus. Acc. Bd., Bul. No. |