SETTLEMENT OF CLAIMED VIOLATION OFA SPECIFIC SAFETY REQUIREMENT INDUSTRIAL COMMISSION OF OHIOCLAIMNUMBER: SOCIALSECURITY#:Employer'sAddressNAME)ADDRESSADDRESSCOUNTY NAMEPHONE(CITY, STATE, ZIP CODECITY, STATE, ZIP CODE Address on VSSR is new Injured Worker's Address) (Injured Worker's Representative'sEmployer'sRepresentative'sNAME PHONENAMEThis agreement entered into thisday of20, by and between,"Injured Worker" , and, the "Employer" atstate of.The Injured Worker, while working for the Employer, received work-related injuries on or aboutwhichresulted in a claim being filed by Injured Worker for the payment of Workers' Compensation benefits and medical services, being claim #, which has been allowed for the following conditions:After filing of the original claim, Injured Worker filed an application for additional award for violation of specificsafety requirement(s) on claiming that Employer violated one or more requirement(s) of the specific safety requirements of the Ohio Industrial Commission and / or the Bureau of Workers' Compensation, and that such violation resulted in His/Her injury as allowed above, andThe parties now desire to make a full and complete lump sum settlement of the Injured Workers' application,subject to the approval of the Industrial Commission, as follows;Employer promises and agrees to pay Injured Worker a lump sum of, and InjuredWorker agrees to accept said sum offrom Employer in full and complete settlement andsatisfaction of Injured Worker's application for an additional award of benefits based on lost wages compensation because of the claimed violation of a specific safety requirement(s) based on injuries sustained on or about .Injured Worker agrees and understands that by accepting this lump sum payment, he / she releases and foreverdischarges Employer, the Industrial Commission, the Bureau of Workers' Compensation and the Ohio State Workers' Compensation Insurance Fund from any and all claims or demands, present or future, that might otherwise be made against Employer because of Employer's claimed violation of a specific safety requirement.Injured Worker shall sign or cause to be signed such other instruments including a receipt and release, as maybe necessary to complete this settlement agreement. This agreement shall be submitted to the Industrial Commission of Ohio for approval, and Employer shall not pay the agreed amount until this agreement shall have been approved by the the Industrial Commision and made a matter of record in the Claim.#. This agree-ment to settle the claimed safety violation is not an admission of responsibility by the Employer.Nothing in this agreement shall be construed to settle or release Injured Worker's claim for regular Workers'Compensation benefits to which he may be lawfully entitled for injuries he received on or about.This agreement is not intended to change any other legal relationships between Injured Worker and Employer. It is the intention of the parties that this settlement cover only the application for additional benefits because of the claimed violation of a specific safety requirement which Injured Worker filed on.The parties have signedthis agreement at the time and place stated.Injured Worker's signatureEmployer's signatureWitnesses signatureWitnesses signatureW A I V E RBoth Injured Worker and Employer have a right to a hearing on this agreement, and are also entitled to a full and complete investigation of the facts and circumstances of the claimed violation. By signing below, both Injured Worker and Employer waive this hearing and notice of hearing, and request immediate end of any investigation now in progress.Injured Worker's signatureEmployer's signatureWitnesses signatureWitnesses signatureOIC1084(7/98)2002 © American LegalNet, Inc.
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