
Last updated: 4/13/2015
Self Insured Joint Settlement Agreement And Release {BWC-7242}
Start Your Free Trial $ 12.99What you get:
- Instant access to fillable Microsoft Word or PDF forms.
- Minimize the risk of using outdated forms and eliminate rejected fillings.
- Largest forms database in the USA with more than 80,000 federal, state and agency forms.
- Download, edit, auto-fill multiple forms at once in MS Word using our Forms Workflow Ribbon
- Trusted by 1,000s of Attorneys and Legal Professionals
Description
Self-insured Joint Settlement Agreement and Release Instructions · Please print or type · Please file completed application at the nearest regional office of the Industrial Commission of Ohio (IC.) Injured worker name Employer name Social Security number Claim number Date of injury/occupational disease I, _____________________________________________and ______________________________________________agree to make (the injured worker) (the employer) settlement in the amount of $ ______________________. 1. By agreeing to the above amount, I, the injured worker, forever release and discharge the employer; its officers; employees; agents; representatives; successors and assigns; the IC; BWC; the Ohio State Insurance Fund; and all persons, firms or corporations from any and all self insured claims, demands, actions or causes of action incurred on or before the date of this agreement, which I now have (or I may later claim to have), whether known or unknown, developing out of my employment with this employer or any other employer. The injured worker and employer also agree that if the above claim (or any other claim(s) being settled), were recognized or allowed prior to the date of this agreement, then the cost of all medical, pharmacy or hospital bills, nursing services, etc., filed with the employer is the responsibility of the employer. If such medical costs occurred before the date of this agreement, but not filed with the employer before the date of this agreement, the cost of those services shall be the responsibility of the injured worker. All costs of medical, pharmacy or hospital bills, nursing services, etc., provided to the injured worker on or after the date of this agreement is also the injured worker's responsibility. 3. The injured worker and employer agree to exclude the following claim (or claims) from this settlement: 2. 4. Additional terms of this settlement agreement are: The injured worker and employer have signed this final settlement agreement on the date indicated and agree the effective date of this agreement is _________________________. This date remains in effect unless denied by the IC within 30 days of the effective date, or the injured worker or employer withdraws this agreement within 30 days of the date of this agreement. Injured worker signature Current address City State Date Employer signature By: Date Nine-digit ZIP code State of Ohio - County I, ___________________________, state that the injured worker personally appeared before me. The injured worker acknowledges the execution of this agreement for final settlement was made of his/her free will. The injured worker acknowledges this agreement between him/her and the employer will result in a complete and final settlement of all claims listed in this settlement. In witness thereof, I have set my hand and official seal, this _____ day of ____________________, 20 ____. Notary public I, ______________________________________, certify I am the attorney of record for this injured worker. Before signing this settlement agreement, the injured worker either read the agreement or the agreement was read and explained to them. The injured worker stated he or she was satisfied with this settlement. Attorney of record signature BWC-7242 (Rev. 1/12/2005) SI-42 American LegalNet, Inc. www.FormsWorkFlow.com
Related forms
-
Acknowledgment Of The Self Insured Joint Settlement Agreement And Release
Ohio/Workers Comp/Employers/ -
Application For Adjustment Of Claim In Case Of Death Due To Occupational Disease
Ohio/Workers Comp/Employers/ -
Application For Handicap Reimbursement
Ohio/Workers Comp/Employers/ -
Self Insured Joint Settlement Agreement And Release
Ohio/Workers Comp/Employers/ -
Self-Insured Employer Injured Worker Screening
Ohio/Workers Comp/Employers/ -
BWC Subrogation Referral Form
Ohio/Workers Comp/Employers/ -
Permanent Authorization
Ohio/Workers Comp/Employers/ -
Application For One Claim Program
Ohio/Workers Comp/Employers/ -
Professional Employer Organization Client Relationship Notification
Ohio/Workers Comp/Employers/ -
Salary Continuation Agreement
Ohio/Workers Comp/Employers/ -
Temporary Authorization To Review Information
Ohio/Workers Comp/Employers/ -
Application For Deductible Program
Ohio/Workers Comp/Employers/ -
Self Insured Semiannual report Of Claim Payments
Ohio/Workers Comp/Employers/ -
Sponsor Certification Application
Ohio/Workers Comp/Employers/ -
Accident Report
Ohio/Workers Comp/Employers/ -
Drug Free Safety Program Safety Action Plan
Ohio/Workers Comp/Employers/ -
Application For Industry Specific Safety Program
Ohio/Workers Comp/Employers/ -
Safety Management Self Assessment
Ohio/Workers Comp/Employers/ -
Waiver Of Appeal Period
Ohio/Workers Comp/Employers/ -
Self-Insurers Agreement As To Compensation On Account Of Death
Ohio/Workers Comp/Employers/ -
Objection To Tentative Order
Ohio/Workers Comp/Employers/ -
Opt Out Of .99 EM Construction Cap Program
Ohio/Workers Comp/Employers/ -
Application For Drug Safety Program
Ohio/Workers Comp/Employers/ -
Application For Representative Identification Number (RN)
Ohio/Workers Comp/Employers/ -
Application For Retrospective Rating Plan For Public Employers
Ohio/Workers Comp/Employers/ -
Employer Report Of Employee Earnings
Ohio/Workers Comp/Employers/ -
Lump Sum Settlement (LSS)
Ohio/Workers Comp/Employers/ -
Request To Correct Employer And Or Policy Number Assignment
Ohio/Workers Comp/Employers/ -
Self-Insured Employers Certification Of Assignment After Initial Allowance
Ohio/Workers Comp/Employers/ -
State Fund Employers Agreement To Accept Claim Assignment
Ohio/Workers Comp/Employers/ -
Notice To BWC Of Agreement To Send Check To Employer
Ohio/Workers Comp/Employers/ -
Application For Adjudication Hearing
Ohio/Workers Comp/Employers/ -
Application For Certification Of Qualified Health PLan (QHP)
Ohio/Workers Comp/Employers/ -
Employer Report Of Employee Earnings For Wage Loss Compensation
Ohio/Workers Comp/Employers/ -
MCO Selection Form
Ohio/Workers Comp/Employers/ -
Application For Workplace Wellness Grant Program
Ohio/Workers Comp/Employers/ -
Transitional Work Grant Program Corporate Analysis Questionnaire Work Sheet
Ohio/Workers Comp/Employers/ -
Employer Trainers Report
Ohio/Workers Comp/Employers/ -
Pre-audit Questionnaire
Ohio/Workers Comp/Employers/ -
Waiver Of Examination Statewide Disability Evaluation System
Ohio/Workers Comp/Employers/ -
Report Of Paid Compensation And Statistical Information
Ohio/Workers Comp/Employers/ -
Employer Authorized Representative (R-2)
Ohio/Workers Comp/Employers/ -
Settlement Application For Non-complying Employer Claims
Ohio/Workers Comp/Employers/ -
Settlement Agreement And Application For Approval Of Settlement Agreement
Ohio/Workers Comp/Employers/ -
Sharps Injury Form Needlestick Report
Ohio/Workers Comp/Employers/ -
Notice Of Intent To Settle
Ohio/7 Workers Comp/Employers/ -
Division Of Safety And Hygiene Annual Report
Ohio/7 Workers Comp/Employers/ -
Complaint (Risk Reduction Program)
Ohio/7 Workers Comp/Employers/ -
Certification Safety Agreement For Sponsors And Affiliate Sponsors
Ohio/7 Workers Comp/Employers/ -
Waiver Of Workers Compensation Benefits For Recreational Or Fitness Activities
Ohio/Workers Comp/Employers/ -
Application For Transitional Work Grant Program
Ohio/7 Workers Comp/Employers/ -
Transitional Work Grant Reimbursement Request Form
Ohio/7 Workers Comp/Employers/ -
Request To Charge Surplus Fund For Vehicle Accident
Ohio/Workers Comp/Employers/ -
Application For Elective Coverage
Ohio/Workers Comp/Employers/ -
Notification Of Business Aquisition Or Merger Or Purchase Or Sale
Ohio/Workers Comp/Employers/ -
Notification Of Policy Update
Ohio/Workers Comp/Employers/ -
Substance Use Recovery Program Enrollment
Ohio/7 Workers Comp/Employers/ -
Fall Protection In Construction Supplemental Questions
Ohio/7 Workers Comp/Employers/ -
Other States Coverage Trucking Supplemental Application
Ohio/Workers Comp/Employers/ -
Labor Lease Transaction Payroll
Ohio/Workers Comp/Employers/ -
Labor Lease Transaction Claims
Ohio/Workers Comp/Employers/ -
Request For Business Transfer Information
Ohio/Workers Comp/Employers/ -
Amended True-Up Payroll Report
Ohio/Workers Comp/Employers/ -
Non Ohio Amended Payroll Report
Ohio/Workers Comp/Employers/ -
Contract For Coverage Of State Agency Of Political Subdivision
Ohio/Workers Comp/Employers/ -
Apprenticeship Elective Coverage Contract
Ohio/Workers Comp/Employers/ -
Notice Of Election To Obtain Coverage From Other States
Ohio/Workers Comp/Employers/ -
Agreement To Select The State Of Ohio As The State Of Exclusive Remedy
Ohio/Workers Comp/Employers/ -
Agreement To Select A State Other Then Ohio As The State Of Exclusive Remedy
Ohio/Workers Comp/Employers/ -
Application For Exemption From Ohio Workers Coverage And Waiver Of Benefits
Ohio/Workers Comp/Employers/ -
Request For Retroactive Coverage And Penalty Abatement
Ohio/Workers Comp/Employers/ -
Filing Of An Allegation Against A Self Insured Employer
Ohio/7 Workers Comp/Employers/ -
Application For Coverage
Ohio/Workers Comp/Employers/ -
Transitional Work Grant Agreement
Ohio/Workers Comp/Employers/ -
Transitional Work Offer And Acceptance Form
Ohio/Workers Comp/Employers/ -
Election To Withdraw From Claims Reimbursement Fund
Ohio/Workers Comp/Employers/ -
Initial Application By Employer For Authority To Pay Compensation Directly
Ohio/Workers Comp/Employers/ -
Self-Insured Claims Reimbursement (Sysco) Application
Ohio/Workers Comp/Employers/ -
Self-Insured Construction Project Application
Ohio/Workers Comp/Employers/ -
Unconditional And Continuing Guarantee
Ohio/Workers Comp/Employers/ -
Agreement Between Employer And The Ohio Bureau Of Workers Compensation Regarding Amount Of Self Insured Buyout
Ohio/Workers Comp/Employers/ -
Application To Add A Subsidiary To An Existing Self Insured Policy
Ohio/7 Workers Comp/Employers/ -
Application For Transitional Work Bonus Program
Ohio/Workers Comp/Employers/
Form Preview
Contact Us
Success: Your message was sent.
Thank you!