Section 15. Stipulated Settlements

   (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. However, if you are only settling a "Medical Only" claim, you shall create a Board file by filing a WC-14 and/or WC-1 with Section C or D completed;

   (3) if a WC-1 has not previously been filed with the Board, the Board may require the attachment of a copy of the Form WC-1 with Section B, C, or D completed for each date of accident included in the caption;

   (4) if an attorney fee contract has not previously been filed with the Board, attach a copy of the fee contract of counsel for the employee/claimant; and,

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

   (6) 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.

   (7) 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;

   (8) All stipulations shall be limited to no more than 25 pages, 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;

   (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; and,

   (3) 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.

(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) When the agreement provides for the employer/insurer to fund any portion of the settlement by purchase of an annuity or other structured settlement instrument, which provides for a third party to pay such portion of the settlement, then the stipulation must contain a provision that the employer and insurer will be liable for the payments in the event of the default or failure of the 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 or projected 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. Any expense, cost, surcharge, flat fee or averaged expenditure which is not reasonable and solely related to the case being settled shall not be approved by the Board. 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. No portion of any settlement payment shall be designated as medical except the amount specified in the approved stipulation.

(f) 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 confidential informal inquiry regarding any settlement.

(i) When filing a motion for reconsideration on the approval or denial of a settlement, the parties or attorneys shall: (1) immediately notify the Division Director of the Settlement Division or the Board by telephone call; (2) use the ICMS doc-type labeled motion for reconsideration; (3) limit their request to 10 pages, including briefs and exhibits, unless otherwise permitted by the Board; and (4) serve a copy on all counsel and unrepresented parties, along with supporting documents, including a separate certificate of service identifying the names and addresses served.

(j) In any stipulated settlement agreement where review by the Centers for Medicare and Medicaid Services (CMS) is available, the parties elect to pursue approval of the proposed Medicare Set Aside (MSA) by CMS, and the parties elect to submit the settlement agreement to the Board for approval prior to CMS approval, the parties shall acknowledge and agree that the State Board of Workers' Compensation shall retain jurisdiction of those medical issues covered by the MSA until such time as the medical portion of the claim is resolved in accordance with the Workers' Compensation Act.

(k) No party or any party's attorney shall enter into a loan or assignment with a third party creditor which requires repayment from the proceeds of a workers' compensation claim.

(l) The employee shall stipulate that there are no outstanding child support liens that would prohibit full disbursement of the settlement funds in this case.

(m) For settlements of $5000.00 or more, the Board or any party to the settlement agreement may require that the settlement documents contain language which prorates the lump sum settlement over the life expectancy of the injured worker.

(n) Settlements in compensable claims will not be approved unless all WC-206/WC-244 party at interest issues are resolved.

(o) In all no-liability settlements, the parties shall submit a statement specifying the party responsible for outstanding medical expenses.