Claimants Affidavit In Support Of Settlement {H-05}

Workers Compensation Commission CLAIMANTS AFFIDAVIT IN SUPPORT OF SETTLEMENT I, , am the claimant in claim # . I ask the Workers Compensation Commission to approve the settlement of my claim and in support of this request state: 1. that I am voluntarily settling my claim ; 2. that in so doing I am giving up the following rights: a. the right to hearings before the Workers Compensation Commission for resolution of any dispute rsegarding my claim; b. the right to vocationa lrehabilitation service sand to payment during my lifetime for any medica tlreatment related to my claim, exce ptas provided, if a tall, in this settlement; c. the right, except as provided, if a tall, in this settlement, to be compensated, under certain conditions, by the Subsequent Injury Fund for permane ntimpairments incurred before the accidental injury or occupational disease which gave rise to my claim; d. the right to ask the Workers Compensation Commission, within 5 yea of rsthe last payment of any compensation th aitt might have ordered, to reopen my claim should my condition related to my claim wors en; e. the right to appea lto the appropriate Circuit Court if I were dissatisfied with a decision of the Workers Compensation Commission; f. the right to appeal to the Court o fSpecial Appeals if I were dissatisfied with the decision of the Circuit Court; and g. the right to petition the Court of Appeals to review the decision of the Court of Special Appeals if I were dissatisfied with the decision of the Court of Special Appeals; and 3. that, by signin gthis affidavit, I acknowledg ethat I have read, and understand, t heterms of this settlement and al lthe documents attached in support of it, including medical reports and this affidavit. I, as attorney for the claimant, have reviewed ___________________________________ this Affidavit with the claimant. Claimants Signature C laimants Name (printed) Attorney for Claimant Date Date 10 East Baltimore Street l Baltimore, Maryland 21202-1641 410-864-5100 l Email: info@wcc.state.md.us l Web: http://www.wcc.state.md.us WCCH-05 (Rev. 9/05/03)