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Third Party Compromise And Release DWC-CA 10214(e) - California
| Third Party 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 THIRD PARTY 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 Street Address/PO Box (Please leave blank spaces between numbers, names or words) City Employer (Completion of this section is required) State Zip Code Name (Please leave blank spaces between numbers, names or words) Address/PO Box (Please leave blank spaces between numbers, names or words) City DWC-CA form 10214 (e) (PAGE 1) (REV. 11/2008) State Zip Code Applicant's Attorney or Authorized Representative: Law Firm/Attorney Non Attorney Representative First Name Last Name Firm Number Law Firm Name Street 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 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 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 (e) (PAGE 2) (REV. 11/2008) State Zip Code Claims Administrator Information (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 The parties hereto, for the purpose of compromise only, hereby submit the following agreed statements of fact: 1. born on MM/DD/YYYY , claims that he was employed on the day of , at (Month) (Year) (city) , as a(n) State by (Occupation) then insured as (Name of employer) to workers' compensation liability by (State name of carrier or whether self insured) , sustained an injury arising out of and in the course of his employment as follows: 2. The actual weekly wages of the employee at the time of injury were $ while the average weekly wages were $ 3. The employee's present disability is (State present disability resulting from injury) . and the employee returned to work (If so when) . 4. (a) Temporary disability indemnity has been paid to the employee in the sum of $ at $ per week covering MM/DD/YYYY to . MM/DD/YYYY the amount due and unpaid to the employee is $ (b) Permanent disability indemnity has been paid to the employee in the sum of $ covering period from MM/DD/YYYY to . MM/DD/YYYY DWC-CA form 10214 (e) (PAGE 3) (REV. 11/2008) 5. Medical and hospital expenses have been paid $ by employer or carrier. Unpaid bills amount to $ is estimated at $ . by the employee and $ . Future medical and hospital expense Unpaid and future medical and hospital expense is to be assumed as follows: 6. Name and address of employee's attorney, if any Law Firm or Company Name (If Applicable) Attorney/Rep First Name MI Attorney/Rep Last Name Address/PO Box (Please leave blank spaces between numbers, names or words) Suite/Apt# City State Zip Code 7. It is claimed that the injury to the employee was caused by the negligence of An agreement has been reached for settlement in full of the employee's claim for personal injury against said alleged tort-feasor for the sum of $ . Yes No 8. Copy of settlement agreement between employee and the alleged tort-feasor is attached. (Copy must be attached if in writing, or explanation given) 9. From said sum the employee's attorney requests a fee of $ and $ for expenses incurred [Note attach supporting statements, e.g. Court agreement, services rendered, etc. See Labor Code section 3860(f)] leaving a balance of $ to be divided between the employee and the . To Employee $ (Carrier or Self insured) . Court approval documents attached To: (Carrier or Self insured) to carrier or self insured employer $ . 10. Reason for compromise (include issues that would be raised in event of proceedings under provisions of paragraph 13) DWC-CA form 10214 (e) (PAGE 4) (REV. 11/2008) 11. The undersigned request that this compromise Agreement and Release be approved. 12. Upon approval of this Compromise Agreement by the Workers' Compensation Appeals Board and payment in accordance with the provisions hereof, said employee releases and forever discharges said employer and insurance carrier from all claims and cause of action, whether now known or ascertained, or which may hereafter arise or develop as a result of said injury, including any and all liability of said employer and said insurance carrier and each of them to the dependents, heirs, executors, representatives, administrators or assigns of said employee. 13. It is agreed by all parties hereto that the filing of this document is the filing of an application on behalf of employee and that the workers' compensation administrative law judge may in his or her discretion set the matter for hearing as a regular application, reserving to the parties the right to put in issue any of the facts admitted herein, and that if hearing is held with this document used as an application the defendants shall have available to them all defenses that were available as of date of filing of this document, and that the workers' compensation administrative law judge may thereafter either approve said Compromise Agreement and Release or disapprove the same and issue Findings and Award after hearing has been held and the matter regularly submitted for decision. 14. For the purpose of determining the lien claim filed herein for the unemployment compensation disability benefits or unemployment compensation benefits and extended duration benefits which have been paid under or pursuant to the California Unemployment Insurance Code, the parties propose the following division of the sum agreed upon for settlement and release of this case. $ $ $ $ for temporary disability covering the period fo
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