Pennsylvania > Workers Comp
Compromise And Release Agreement LIBC-755 - Pennsylvania
| Compromise And Release Agreement Form. This is a Pennsylvania form and can be used in Workers Comp . |
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COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800.482.2383 TTY 800.362.4228 www.dli.state.pa.us COMPROMISE AND RELEASE AGREEMENT BY STIPULATION PURSUANT TO SECTION 449 OF THE WORKERS' COMPENSATION ACT Employer Name Street 1 Street 2 City/Town County Telephone ( ) - Date of Injury: MM / DD / YYYY PA BWC Claim Number: (IF KNOWN) Employee First Name Street 1 Last Name Street 2 City/Town State Zip Code State Zip Code - County Telephone - ( ) FEIN TO THE PARTIES: DO NOT SUBMIT THIS AGREEMENT TO THE BUREAU. SUBMIT IT TO THE ASSIGNED WORKERS' COMPENSATION JUDGE. TO THE EXTENT THIS AGREEMENT REFERENCES AN INJURY FOR WHICH LIABILITY HAS NOT BEEN RECOGNIZED BY AGREEMENT OR BY ADJUDICATION, THE TERM "INJURY" AS USED IN THIS AGREEMENT SHALL MEAN "ALLEGED INJURY." "FUND" SHALL MEAN THE UEGF, SIF, SIGF OR PRE-SIGF. This form must be used as of February 1, 2011. Prior versions of the form will no longer be accepted. Insurer, Fund or Third Party Administrator (if self-insured) Name Street 1 Street 2 City/Town County Telephone ( ) FEIN Bureau Code State Zip Code - Insurer/TPA Claim Number This is an agreement in the case of the above listed employee and the above listed employer, insurer, Fund or third party administrator in regards to an injury or occupational disease. 1. State the date of injury or occupational disease. ______/ ______/ _________ MM DD YYYY 2. State the average weekly wage of the employee, as calculated under Section 309. $ _____________ . _____/wk 3. State the weekly compensation rate paid or payable. $ _____________ . _____/wk 4. State the precise nature of the injury and whether the disability is total or partial. LIBC-755 REV 01-11 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com 5. State the amount of benefits paid or due and unpaid to the employee or dependent up to the date of this agreement or death. Wage loss: $ . Specific Loss: $ . Medical: . 6. Is this Compromise and Release Agreement a resolution of wage loss benefits for the injury referenced in Paragraphs 1 and 4? yes no 7. Is this Compromise and Release Agreement a resolution of medical benefits for the injury referenced in Paragraphs 1 and 4? yes no 8. Is this Compromise and Release Agreement a resolution of specific loss benefits for the injury referenced in Paragraphs 1 and 4? yes no 9. Does this claim arise out of the death of an employee? o Yes If Yes, complete and attach a Death Claim Supplement. o No 10. Summarize all wage loss, specific loss and medical benefits to be paid in conjunction with this Compromise and Release Agreement: 11. Is there an actual or potential lien for subrogation under Section 319? o Yes o No If Yes, state (if known) the total amount of compensation, including medicals, paid or payable, which should be allowed to the employer or insurer. 12. Are there any current child or spousal support orders in place against the claimant o Yes o No Verification pursuant to Special Rules of Administrative Practice and Procedure before Workers' Compensation Judges, Rule 131.111(c), must be attached. If Yes, provide details: 13. List all benefits received by, or available to, the claimant; e.g. Social Security (Disability or Retirement) private health insurance, Medicare, Medicaid, etc. LIBC-755 REV 01-11 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com 14. This Compromise and Release Agreement addresses the interests of Medicare in accordance with the Medicare Secondary Payer Statute (42 U.S.C. Section 1395(y)): a) Manner in which Medicare's interests have been addressed: b) Amount allocated: $ . c) Manner in which conditional payments have been addressed: 15. Check as appropriate: o A vocational evaluation of the employee was completed in conjunction with this Compromise and Release on / / by . A copy of this report must be attached. -ORA vocational evaluation of the employee has been waived by mutual agreement of the parties. o 16. State the issues involved in this claim and the reasons why the parties are entering into this agreement. 17. A copy of the fee agreement between employee and counsel must be attached. State the amount of the fee: $ . . 18. Litigation costs in the total amount of $ 19. State additional terms and provisions, if any: . shall be the responsibilty of . REMINDER TO PARTIES: Upon approval of this Agreement, please promptly withdraw all appeals pending before the Workers' Compensation Appeal Board, Commonwealth Court, Pennsylvania Supreme Court, etc., which are also resolved by this Agreement. LIBC-755 REV 01-11 (Page 3) American LegalNet, Inc. www.FormsWorkFlow.com EMPLOYEE'S CERTIFICATION 1. I certify that I have read this entire agreement, or to the best of my knowledge, information and belief (if applicable) this agreement has been read to me, and I understand all of the contents of this agreement as well as the full legal significance and consequences of entering into this agreement. 2. I understand that, if this agreement is approved, I will receive only the benefits mentioned in this agreement, unless the agreement provides specifically for additional amounts. I understand that my employer, its insurance company or its administrator will never have to pay any other workers' compensation benefits for the injury. 3. Except for the amounts or benefits listed in this agreement, I have been offered nothing of value to convince me to sign this agreement. 4. I have been represented by an attorney of my own choosing during this case. My attorney has explained to me the content of this agreement and its effects upon my rights. __________ (Employee's Initials) - OR I have not been represented by an attorney of my own choosing. However, I have been told that I have the right to be represented by an attorney of my own choosing in this proceeding. I have made my own decision not to have an attorney represent me. __________ (Employee's Initials) 5. Unless specifically stated in this agreement, I understand that this agreement is a compromise and release of a workers' compensation claim, and is not considered an admission of liability by employer and/or insurer and/or administrator and/or Fund. DO NOT SIGN THIS DOCUMENT UNLESS YOU UNDERSTAND THE FULL LEGAL SIGNIFICANCE OF THIS AGREEMENT. All parties have read this agreement and agree to its contents. We understand that under this agreement, all petitions are resolved. Dated: ______ / ______ / ________
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