Workers' Compensation Compromise and Release

COMPROMISE AND RELEASE AGREEMENT

(Full and Final Workers' Compensation Settlement with Medical Buyout)

PART 1: CASE INFORMATION

1.1 Administrative Information

WCAB/Board Case Number: [ADJ NUMBER]

District Office: [LOCATION]

Claims Administrator Claim Number: [NUMBER]

1.2 Injury Information

Date of Injury: [DATE]

Date Last Worked: [DATE]

Specific/Cumulative: ☐ Specific Date of Injury ☐ Cumulative Trauma

If Cumulative, Period of Exposure: From [DATE] to [DATE]

PART 2: PARTIES

2.1 Injured Worker (Applicant)

Name: [FULL LEGAL NAME]

Social Security Number: [XXX-XX-XXXX]

Date of Birth: [DATE]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Telephone: [PHONE]

Occupation at Time of Injury: [JOB TITLE]

Current Employment Status:
☐ Employed by same employer
☐ Employed elsewhere
☐ Unemployed
☐ Retired
☐ Receiving Social Security Disability

2.2 Employer (Defendant)

Employer Name: [LEGAL NAME]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Nature of Business: [DESCRIPTION]

2.3 Insurance Carrier/Claims Administrator

Name: [NAME]

Policy Number: [NUMBER]

Policy Period: [START DATE] to [END DATE]

Adjusting Location:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Claim Examiner: [NAME]

Phone: [PHONE]

PART 3: ATTORNEYS

3.1 Applicant's Attorney

☐ Applicant is represented by counsel
☐ Applicant is not represented (pro per)

Attorney Name: [NAME]

State Bar Number: [NUMBER]

Firm Name: [FIRM]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Telephone: [PHONE]

Fax: [FAX]

Email: [EMAIL]

3.2 Defendant's Attorney

Attorney Name: [NAME]

State Bar Number: [NUMBER]

Firm Name: [FIRM]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Telephone: [PHONE]

PART 4: STATEMENT OF ISSUES AND DISPUTES

4.1 Body Parts Claimed

Applicant claims injury to the following body parts:

[LIST ALL BODY PARTS - e.g., lumbar spine, cervical spine, left shoulder, psyche, etc.]

4.2 Issues in Dispute

The following issues were disputed and are being compromised by this settlement:

☐ Compensability/AOE-COE (Arising Out of Employment/Course of Employment)
☐ Body parts in dispute: [LIST]
☐ Permanent disability rating
☐ Need for future medical treatment
☐ Apportionment
☐ Temporary disability owed
☐ Date of maximum medical improvement
☐ Other: [SPECIFY]

4.3 Statement of Disputes

[DESCRIBE THE NATURE OF THE DISPUTES BEING SETTLED]

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

PART 5: BASIS FOR SETTLEMENT

5.1 Medical Evidence Considered

The following medical reports were considered in reaching this settlement:

5.2 Permanent Disability Evaluation

If Applicant's claim were found compensable, the permanent disability would likely be rated as follows:

Based on QME/AME Report of Dr. [NAME] dated [DATE]:

Disputed Ratings:
Applicant contends: [%] PD
Defendant contends: [%] PD

5.3 Future Medical Care Evaluation

Estimated value of future medical care:

PART 6: BENEFITS PREVIOUSLY PAID

6.1 Temporary Disability

6.2 Permanent Disability Advances

PD Advances Paid: $[AMOUNT]

6.3 Medical Treatment

Approximate Value of Medical Treatment Provided: $[AMOUNT]

6.4 Vocational Rehabilitation/SJDB

Vocational Rehabilitation Benefits Paid: $[AMOUNT]
SJDB Voucher Issued: ☐ Yes ☐ No

6.5 Other Benefits

Other Benefits Paid: $[AMOUNT]
Description: [DESCRIBE]

PART 7: TERMS OF COMPROMISE AND RELEASE

7.1 Settlement Amount

TOTAL GROSS SETTLEMENT AMOUNT: $[AMOUNT]

This amount represents full and final settlement of all claims for:
☐ Permanent disability
☐ Temporary disability (disputed amounts)
☐ Future medical treatment
☐ Supplemental job displacement benefits
☐ All other benefits

7.2 Itemization of Settlement

7.3 Deductions

7.4 Net Settlement

NET AMOUNT PAYABLE TO APPLICANT: $[AMOUNT]

PART 8: LIENS

8.1 Outstanding Liens

The following liens have been filed or asserted against this claim:

8.2 Lien Disposition

☐ All liens have been resolved and will be paid from settlement proceeds
☐ Liens will be paid directly by Defendant
☐ Liens remain disputed and will be resolved separately
☐ Applicant assumes responsibility for unresolved liens

PART 9: FUTURE MEDICAL TREATMENT

9.1 Waiver of Future Medical Treatment

APPLICANT HEREBY WAIVES ALL RIGHTS TO FUTURE MEDICAL TREATMENT FOR THIS INDUSTRIAL INJURY.

By signing this Compromise and Release, Applicant understands and agrees that:

☐ NO FUTURE MEDICAL TREATMENT will be provided by Defendant or Insurance Carrier for any condition arising from or related to this industrial injury.

☐ Applicant will be SOLELY RESPONSIBLE for all future medical costs related to this injury.

☐ This waiver is FINAL and IRREVOCABLE. Applicant CANNOT reopen this claim to obtain medical treatment, even if Applicant's condition significantly worsens.

☐ Applicant has been advised of the estimated value of future medical care (approximately $[AMOUNT]) and has factored this into the decision to settle.

9.2 Applicant's Acknowledgment Regarding Future Medical

Applicant must initial each statement:

_____ I understand that I am giving up ALL rights to future medical treatment for this injury.

_____ I understand that I will be responsible for paying for any future medical care out of my own pocket or through private insurance.

_____ I understand that this decision is final and cannot be changed later.

_____ I have discussed the estimated cost of future medical care with my attorney (if represented).

_____ I have had the opportunity to consult with my treating physician about my future medical needs.

PART 10: MEDICARE PROVISIONS

10.1 Medicare Status

Applicant's Medicare Status:

☐ Applicant is NOT currently a Medicare beneficiary
☐ Applicant IS currently a Medicare beneficiary (Medicare ID: [NUMBER])
☐ Applicant is receiving Social Security Disability Insurance (SSDI)
☐ Applicant has applied for SSDI or Medicare
☐ Applicant has End Stage Renal Disease (ESRD)

Applicant's Date of Birth: [DATE]

Applicant's Age: [AGE]

10.2 Medicare Set-Aside (MSA)

☐ MSA Not Required - Applicant is not a Medicare beneficiary and does not reasonably expect to become one within 30 months.

☐ MSA Included - A Medicare Set-Aside in the amount of $[AMOUNT] is included in this settlement.
- MSA submitted to CMS: ☐ Yes ☐ No
- CMS approval: ☐ Approved ☐ Pending ☐ Not submitted
- MSA will be administered by: [SELF/PROFESSIONAL ADMINISTRATOR]

☐ MSA Waived - The parties have determined that an MSA is not required because:
[EXPLAIN REASON - e.g., no future medical treatment anticipated, claimant has private insurance, etc.]

10.3 Medicare Indemnification

Applicant agrees to indemnify, defend, and hold harmless Defendant and Insurance Carrier from any claims by Medicare or CMS related to this settlement, including conditional payments, demands for reimbursement, or any liability arising from Applicant's failure to properly administer any Medicare Set-Aside.

PART 11: RELEASES AND WAIVERS

11.1 General Release

In consideration of the settlement set forth herein, Applicant hereby FULLY and FOREVER RELEASES and DISCHARGES:

• [EMPLOYER NAME]
• [INSURANCE CARRIER NAME]
• All officers, directors, employees, agents, successors, and assigns of the above
• All parent companies, subsidiaries, and affiliated entities
• All insurance carriers and claims administrators, past and present

(collectively, "Released Parties")

from any and all claims, demands, actions, causes of action, obligations, damages, costs, expenses, attorney fees, and liabilities of every kind and nature whatsoever, whether known or unknown, suspected or unsuspected, that Applicant now has or may hereafter have against the Released Parties arising from or in any way related to the industrial injury of [DATE OF INJURY], including but not limited to:

• All workers' compensation benefits of any kind
• Temporary total disability and temporary partial disability
• Permanent disability
• Future medical treatment
• Supplemental job displacement benefits
• Life pension
• Penalties and interest
• Attorney fees
• Any and all other benefits available under workers' compensation law

11.2 Waiver of Civil Code Section 1542 (California)

APPLICANT EXPRESSLY WAIVES AND RELINQUISHES ALL RIGHTS AND BENEFITS UNDER CALIFORNIA CIVIL CODE SECTION 1542, WHICH PROVIDES:

"A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS THAT THE CREDITOR OR RELEASING PARTY DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE AND THAT, IF KNOWN BY HIM OR HER, WOULD HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR OR RELEASED PARTY."

Applicant Initials: _____

Applicant acknowledges that Applicant may hereafter discover claims or facts in addition to or different from those Applicant now knows or believes to exist, and that such claims are included in this release.

11.3 [YOUR STATE] Unknown Claims Waiver

[INSERT STATE-SPECIFIC LANGUAGE]

PART 12: REPRESENTATIONS, WARRANTIES, AND ACKNOWLEDGMENTS

12.1 Applicant's Representations

Applicant represents, warrants, and acknowledges that:

☐ Applicant has READ this entire Compromise and Release Agreement and UNDERSTANDS its terms.

☐ Applicant enters into this settlement VOLUNTARILY and without coercion.

☐ Applicant understands that this is a FINAL settlement and that Applicant is giving up substantial rights, including the right to future medical treatment.

☐ If represented, Applicant has had adequate opportunity to discuss this settlement with Applicant's attorney and has received satisfactory answers to all questions.

☐ Applicant has NOT been promised anything other than what is set forth in this agreement.

☐ Applicant understands that this settlement CANNOT be reopened or modified after approval, except as specifically allowed by law.

☐ Applicant has accurately disclosed Applicant's Medicare status.

☐ Applicant has disclosed all prior injuries to the body parts being settled.

☐ No one has made any representations about the tax consequences of this settlement. Applicant is advised to consult a tax professional.

12.2 Specific Acknowledgments

Applicant must initial each acknowledgment:

_____ I understand that by signing this C&R, I give up ALL future medical treatment for my work injury - even if my condition gets worse.

_____ I understand that the decision to settle is mine alone and that no one can force me to settle.

_____ I understand that once the Judge approves this settlement, it is FINAL and PERMANENT.

_____ I understand the total amount I will receive is $[NET AMOUNT] after deductions.

_____ I have considered how I will pay for future medical needs after this settlement.

PART 13: PAYMENT

13.1 Payment Terms

Payment shall be made within [NUMBER] days of the Workers' Compensation Judge's approval of this Compromise and Release.

Net Amount: $[AMOUNT]

Make Check Payable To: [PAYEE NAME]

Send Payment To:
[NAME]
[ADDRESS]
[CITY], [STATE] [ZIP CODE]

13.2 Tax Information

Applicant's Social Security Number: [XXX-XX-XXXX]

☐ Form 1099 will be issued (if required)

PART 14: SIGNATURES

14.1 Applicant

I have read and understand this Compromise and Release Agreement. I agree to all of its terms.

Signature: _________________________________

Printed Name: [NAME]

Date: [DATE]

14.2 Applicant's Attorney

I am the attorney for Applicant. I have explained this Compromise and Release to my client and believe it is in my client's best interest. I recommend approval.

Signature: _________________________________

Printed Name: [NAME]

State Bar Number: [NUMBER]

Date: [DATE]

14.3 Defendant's Attorney

On behalf of Defendant and [INSURANCE CARRIER], I agree to the terms of this Compromise and Release.

Signature: _________________________________

Printed Name: [NAME]

State Bar Number: [NUMBER]

Date: [DATE]

PART 15: ORDER APPROVING COMPROMISE AND RELEASE

FOR WORKERS' COMPENSATION JUDGE USE ONLY

CASE NUMBER: [NUMBER]

Good cause appearing, IT IS ORDERED that:

☐ The Compromise and Release Agreement is APPROVED.

☐ The attorney fee of $[AMOUNT] ([__]%) is APPROVED and shall be paid from the settlement proceeds.

☐ The settlement is adequate and reasonable.

☐ The Applicant understands the consequences of this settlement, including the waiver of future medical treatment.

☐ All issues in this case are resolved.

ORDERED this [DAY] day of [MONTH], [YEAR].

Workers' Compensation Judge Signature: _________________________________

Printed Name: Hon. [NAME]

[END OF DOCUMENT]