Sec. 14.09.09.04. Stipulation for Permanent Disability

A. A written stipulation to an award for permanent disability shall be filed using the Stipulation of Parties and Award of Compensation form and contain the following information:

(1) The claimant's average weekly wage;

(2) The inclusive dates of any temporary total disability;

(3) The inclusive dates and rate of any temporary partial disability;

(4) A copy of any medical evaluation relied upon;

(5) The percentage of claimant's loss of use or industrial loss of use and the benefits weeks payable;

(6) Any medical expenses claimed;

(7) Any attorney's fees sought by claimant's attorney; and

(8) The signatures of all parties if a written stipulation is submitted.

B. If the claimant is not represented by an attorney, the stipulation shall be accompanied by the following:

(1) All medical information in the possession of other parties; and

(2) A statement signed by the claimant acknowledging that the claimant understands that the stipulation does not foreclose the claimant's future right to benefits under the Workers' Compensation Law, including the right to reopen and the right to continuing medical treatment.

C. The stipulation is not binding on the Commission.