Acknowledgment Of The Self Insured Joint Settlement Agreement And Release {BWC-7243} | Pdf Fpdf Doc Docx | Ohio

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Acknowledgment Of The Self Insured Joint Settlement Agreement And Release {BWC-7243} | Pdf Fpdf Doc Docx | Ohio

Last updated: 4/13/2015

Acknowledgment Of The Self Insured Joint Settlement Agreement And Release {BWC-7243}

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Description

Acknowledgment of the Self-insured Joint Settlement Agreement and Release Instructions · Please print or type · Please attach to the Self-insured Joint Settlement Agreement and Release and file both completed forms at the nearest regional office of the Industrial Commission of Ohio (IC). Injured worker name Employer name Risk number Claim number Date I, ________________________________, certify my attorney ____________________________ has (injured worker) totally explained to me all areas of the settlement application/agreement that I have agreed to, with the self insured employer named above. I understand that by agreeing to the attached application/agreement: 1. I will not receive payment from the self-insured employer, BWC or IC for any future compensation, medical bills or any other benefits as outlined in the Self-insured Joint Settlement Agreement and Release; That any amount paid to me because of this settlement/agreement is subject to any valid court-ordered child support payments; That I may also be required, because of my contractual relationship with my attorney, to pay attorney fees because of their representation in the negotiation and completion of the settlement/agreement. 2. 3. Injured worker signature Attorney of record signature Date Date BWC-7243 (10/2/1997) SI-43 American LegalNet, Inc. www.FormsWorkFlow.com

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