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Compromise And Release DWC-CA 10214(c) - California

Compromise And Release Form. This is a California form and can be used in EAMS Forms Workers Comp .
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STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD COMPROMISE AND RELEASE Case Number 1 Case Number 4 Case Number 2 Case Number 5 Case Number 3 SSN (Numbers Only) Venue Choice is based upon: (Completion of this section is required) County of residence of employee (Labor Code section 5501.5(a)(1) or (d).) County where injury occurred (Labor Code section 5501.5(a)(2) or (d).) County of principal place of business of employee's attorney (Labor Code section 5501.5(a)(3) or (d).) Select 3 Letter Office Code For Place/Venue of Hearing (From Document Cover Sheet) Employee(Completion of this section is required) First Name MI Last Name Address/PO Box (Please leave blank spaces between numbers, names or words) City Employer Information (Completion of this section is required) Insured Self-Insured Legally Uninsured State Uninsured Zip Code Employer Name (Please leave blank spaces between numbers, names or words) Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) City DWC-CA form 10214 (c) (Rev. 11/2008) (Page 1 of 9) State Zip Code Applicant's Attorney or Authorized Representative: Law Firm/Attorney Non Attorney Representative First Name Last Name Law Firm Number Law Firm Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Defendant's Attorney or Authorized Representative: Law Firm/Attorney Non Attorney Representative First Name Last Name Law Firm Number Law Firm Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by claims administrator) Insurance Carrier Name (Please leave blank spaces between numbers, names or words) Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) City DWC-CA form 10214 (c) (Rev. 11/2008) (Page 2 of 9) State Zip Code Claims Administrator Information (if known and if applicable) Name (Please leave blank spaces between numbers, names or words) Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code IT IS CLAIMED THAT: 1. The injured employee, born (DATE OF BIRTH: MM/DD/YYYY) , alleges that while employed as a(n) , sustained injury (OCCUPATION AT THE TIME OF INJURY) arising out of and in the course of employment at the locations and during the dates listed below: (State with specificity the date(s) of injury(ies) and what part(s) of body, conditions or systems are being settled.) Specific Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) Case Number 1 Cumulative Injury (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 4: The injury occurred at (Street Address/PO Box - Please leave blank spaces between numbers, names or words) Body Part 2: Other Body Parts: Body Part 3: . , Zip Code City State Body parts, conditions and systems may not be incorporated by reference to medical reports. DWC-CA form 10214 (c) (Rev. 11/2008) (Page 3 of 9) Specific Injury Case Number 2 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 4: The injury occurred at (Street Address/PO Box - Please leave blank spaces between numbers, names or words) Body Part 2: Other Body Parts: Body Part 3: . , City Zip Code State Body parts, conditions and systems may not be incorporated by reference to medical reports. Specific Injury Case Number 3 (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) Cumulative Injury (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 4: The injury occurred at Body Part 2: Other Body Parts: Body Part 3: (Street Address/PO Box - Please leave blank spaces between numbers, names or words) City , State Zip Code . Body parts, conditions and systems may not be incorporated by reference to medical reports. Specific Injury Case Number 4 (Start Date: MM/DD/YYYY) Cumulative Injury (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 3: Body Part 1: Body Part 4: The injury occurred at Body Part 2: Other Body Parts: (Street Address/PO Box - Please leave blank spaces between numbers, names or words) City , State Zip Code . Body parts, conditions and systems may not be incorporated by reference to medical reports. DWC-CA form 10214 (c) (Rev. 11/2008) (Page 4 of 9) Specific Injury Case Number 5 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 4: The injury occurred at (Street Address/PO Box - Please leave blank spaces between numbers, names or words) Body Part 2: Other Body Parts: Body Part 3: City , . State Zip Code Body parts, conditions and systems may not be incorporated by reference to medical reports. 2. Upon approval of this compromise agreement by the Workers' Compensation Appeals Board or a workers' compensation administrative law judge and payment in accordance with the provisions hereof, the employee releases and forever discharges the above-named employer(s) and insurance carrier(s) from all claims and causes of action, whether now known or ascertained or which may hereafter arise or develop as a result of the above-referenced injury(ies), including any and all liability of the employer(s) and the insurance carrier(s) and each of them to the dependents, heirs, executors, representatives, administrators or assigns of the employee. Execution of this form has no effect on claims that are not within the scope of the workers' compensation law or claims that are not subject to the exclusivity provisions of the workers' compensation law, unless otherwise expressly stated. 3. This agreement is limited to settlement of the body parts, conditions, or systems and for the dates of injury set forth in Paragraph No. 1 and further explained in Paragraph No. 9 despite any language to the contrary elsewhere in this document or any addendum. 4. Unless otherwise expressly stated, approval of this agreement RELEASES ANY AND ALL CLAIMS OF APPLICANT'S DEPENDENTS TO DEATH BENEFITS RELATING TO THE INJURY OR INJURIES COVERED BY THIS COMPROMISE AGREEMENT. The parties have considered the release of these benefits in arriving at the sum in Paragraph 7. Any addendum duplicating this langua
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