Workers' Compensation Settlement Agreement

WORKERS' COMPENSATION SETTLEMENT AGREEMENT

(Full and Final Settlement of Workers' Compensation Claim)

TABLE OF CONTENTS

1. Parties and Case Information
2. Recitals and Background
3. Terms of Settlement
4. Payment Provisions
5. Medical Treatment Provisions
6. Releases and Waivers
7. Representations and Warranties
8. Additional Terms
9. Approval and Effective Date
10. Signatures

SECTION 1: PARTIES AND CASE INFORMATION

1.1 Case Identification

WCAB/Board Case Number: [CASE NUMBER]

Claim Number: [CLAIM NUMBER]

Date of Injury: [DATE]

Jurisdiction: [STATE]

1.2 Injured Worker (Applicant)

Name: [FULL LEGAL NAME]

Date of Birth: [DATE]

Social Security Number: [XXX-XX-XXXX]

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

Phone: [PHONE NUMBER]

1.3 Employer (Defendant)

Employer Name: [EMPLOYER LEGAL NAME]

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

1.4 Insurance Carrier

Carrier Name: [CARRIER NAME]

Policy Number: [POLICY NUMBER]

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

1.5 Legal Representation

Applicant's Attorney:
Name: [NAME]
Firm: [FIRM NAME]
Bar Number: [NUMBER]
Address: [ADDRESS]
Phone: [PHONE]

Defendant's Attorney:
Name: [NAME]
Firm: [FIRM NAME]
Bar Number: [NUMBER]
Address: [ADDRESS]
Phone: [PHONE]

SECTION 2: RECITALS AND BACKGROUND

2.1 Recitals

WHEREAS, on or about [DATE OF INJURY], Applicant [APPLICANT NAME] sustained an injury arising out of and in the course of employment with [EMPLOYER NAME];

WHEREAS, Applicant filed a claim for workers' compensation benefits in connection with the alleged injury;

WHEREAS, the parties dispute certain aspects of the claim as set forth herein;

WHEREAS, the parties desire to fully and finally settle and compromise all disputes between them arising from the claimed injury;

NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows:

2.2 Nature of Injury and Claim History

Description of Injury:
[DESCRIBE THE INJURY - include body parts, mechanism of injury, and nature of condition]

____________________________________________________________________________

____________________________________________________________________________

Body Parts Claimed:
[LIST ALL BODY PARTS]

Employment Information:

Job Title at Time of Injury: [JOB TITLE]
Date of Hire: [DATE]
Last Day Worked: [DATE]
Employment Status: ☐ Still employed ☐ Terminated ☐ Resigned ☐ Laid off

Claim History:

• Date Injury Reported: [DATE]
• Date Claim Filed: [DATE]
• Claim Status: ☐ Accepted ☐ Denied ☐ Partially Accepted
• Disputed Issues: [LIST]

2.3 Prior Benefits Paid

Temporary Disability Benefits:

• Period: From [DATE] to [DATE]
• Amount Paid: $[AMOUNT]
• Rate: $[RATE] per week

Permanent Disability Advances:

• Amount Paid: $[AMOUNT]

Medical Treatment:

• Approximate Value of Medical Treatment Provided: $[AMOUNT]

Other Benefits Paid:
[DESCRIBE]

SECTION 3: TERMS OF SETTLEMENT

3.1 Settlement Type

This settlement is a:

☐ COMPROMISE AND RELEASE (C&R)
Full and final settlement of ALL benefits including future medical care.

☐ STIPULATED FINDINGS AND AWARD (STIPS)
Settlement of indemnity benefits with future medical treatment remaining open.

3.2 Settlement Amount

Total Settlement Amount: $[TOTAL AMOUNT]

Breakdown of Settlement:

3.3 Deductions from Settlement

3.4 Net Payment to Applicant

Net Amount Payable to Applicant: $[NET AMOUNT]

3.5 Permanent Disability (for Stipulated Award)

Permanent Disability Rating:

• Whole Person Impairment: [___]%
• Permanent Disability: [___]%
• Basis for Rating: [QME/AME REPORT, DATE]

Permanent Disability Benefits:

• Weekly Rate: $[RATE]
• Number of Weeks: [NUMBER]
• Total PD Value: $[AMOUNT]

Commutation (if applicable):
☐ Benefits to be paid weekly
☐ Benefits commuted to lump sum (explain reason):
____________________________________________________________________________

SECTION 4: PAYMENT PROVISIONS

4.1 Payment Schedule

Payment shall be made as follows:

☐ Lump Sum Payment
The entire net settlement amount of $[AMOUNT] shall be paid within [NUMBER] days of the approval of this settlement by the Workers' Compensation Judge.

☐ Structured Settlement
Payments shall be made according to the following schedule:
[DESCRIBE PAYMENT SCHEDULE]

☐ Periodic Payments (for Stipulated Award)
Permanent disability benefits of $[WEEKLY RATE] shall be paid every [PERIOD] beginning [DATE] and continuing for [NUMBER] weeks.

4.2 Payee Information

Make Payment(s) Payable To:

☐ Applicant: [NAME]

☐ Applicant's Attorney (in trust): [ATTORNEY/FIRM NAME]

☐ Split Payment:

• $[AMOUNT] to [PAYEE]
• $[AMOUNT] to [PAYEE]

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

4.3 Tax Considerations

The parties acknowledge that:

• Workers' compensation benefits are generally excluded from gross income under IRC Section 104(a)(1).
• No tax advice has been provided by any party or attorney in connection with this settlement.
• Applicant is advised to consult with a tax professional regarding any tax implications.

SECTION 5: MEDICAL TREATMENT PROVISIONS

5.1 Future Medical Treatment

Select One:

☐ FUTURE MEDICAL TREATMENT CLOSED (Compromise and Release)

Applicant acknowledges that by accepting this settlement, all rights to future medical treatment for the industrial injury are forever waived and released. The settlement amount includes consideration for the value of future medical care.

Applicant understands that:

• No further medical treatment will be provided by Defendant for this injury
• Applicant is solely responsible for all future medical costs related to this injury
• This waiver is final and cannot be reopened even if Applicant's condition worsens

Estimated value of future medical care included in settlement: $[AMOUNT]

☐ FUTURE MEDICAL TREATMENT REMAINS OPEN (Stipulated Award)

Applicant shall be entitled to reasonable and necessary medical treatment to cure or relieve the effects of the industrial injury, subject to utilization review, for the following body parts:

[LIST BODY PARTS WITH FUTURE MEDICAL AWARD]

Treatment shall be provided through:
☐ The Medical Provider Network (MPN)
☐ Applicant's pre-designated physician
☐ As otherwise allowed by law

5.2 Medicare Set-Aside (MSA) Provisions

Medicare Status:
☐ Applicant is NOT a Medicare beneficiary and does not reasonably expect to become one within 30 months
☐ Applicant IS a Medicare beneficiary or expects to become one within 30 months

If Medicare Beneficiary or Expected:

☐ Medicare Set-Aside (MSA) amount: $[AMOUNT]
☐ MSA submitted to CMS for approval: ☐ Yes ☐ No
☐ CMS approval received: ☐ Yes ☐ No ☐ Pending
☐ MSA will be administered by: [NAME OF ADMINISTRATOR]
☐ MSA not required because: [EXPLAIN]

SECTION 6: RELEASES AND WAIVERS

6.1 Release by Applicant

In consideration of the settlement set forth herein, Applicant hereby fully and forever releases and discharges [EMPLOYER NAME], [INSURANCE CARRIER NAME], and their respective officers, directors, employees, agents, successors, assigns, parent companies, subsidiaries, and affiliates (collectively, "Released Parties") from any and all claims, demands, causes of action, obligations, damages, and liabilities of any kind whatsoever, whether known or unknown, suspected or unsuspected, that Applicant now has or may hereafter have against the Released Parties arising out of or in any way related to the claimed injury of [DATE OF INJURY], including but not limited to:

☐ All claims for workers' compensation benefits under [STATE] law
☐ All claims for temporary disability benefits
☐ All claims for permanent disability benefits
☐ All claims for supplemental job displacement benefits
☐ All claims for vocational rehabilitation
☐ All claims for future medical treatment (if C&R)
☐ All claims for penalties and interest
☐ All other claims arising from the industrial injury

6.2 Waiver of Unknown Claims

California Civil Code Section 1542 Waiver (if applicable):

Applicant hereby 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 acknowledges that this settlement may include claims that Applicant does not currently know or suspect to exist and that such claims are expressly released.

[YOUR STATE] Waiver (if applicable):
[INSERT STATE-SPECIFIC WAIVER LANGUAGE]

6.3 Release by Defendant

Defendant hereby releases Applicant from any and all claims arising out of or related to the processing of this workers' compensation claim, excluding any claims for fraud, misrepresentation, or subrogation rights against third parties.

6.4 Preservation of Rights

Notwithstanding the foregoing releases:

☐ Applicant's right to future medical treatment for the following body parts is preserved: [LIST - for Stips only]

☐ Applicant's right to petition to reopen the claim for new and further disability is preserved for a period of [STATE-SPECIFIC PERIOD - typically 5 years from date of injury]

☐ Any claims against third parties are not affected by this settlement

SECTION 7: REPRESENTATIONS AND WARRANTIES

7.1 Applicant's Representations

Applicant represents and warrants that:

☐ Applicant has been fully advised by counsel regarding the terms and consequences of this settlement.

☐ Applicant understands that by entering into this settlement, Applicant may be giving up valuable rights, including the right to future medical treatment (if C&R).

☐ Applicant has not assigned, transferred, or encumbered any of the claims being released.

☐ Applicant has disclosed all information relevant to this claim, including prior injuries to the same body parts.

☐ Applicant understands that this settlement cannot be rescinded or modified after approval, except as provided by law.

☐ No representations or promises have been made other than those contained in this agreement.

☐ Applicant has had adequate time to consider this settlement and enters into it voluntarily.

☐ Applicant's current Medicare status has been accurately disclosed.

7.2 Defendant's Representations

Defendant represents and warrants that:

☐ Defendant has authority to enter into this settlement.

☐ Payment will be made as set forth herein.

☐ All liens known to Defendant have been disclosed.

SECTION 8: ADDITIONAL TERMS

8.1 Liens

Outstanding Liens:

The following liens are outstanding against this claim:

Lien Resolution:
☐ All liens have been satisfied or resolved
☐ Liens shall be paid from settlement proceeds as follows: [DESCRIBE]
☐ Liens remain disputed and will be resolved separately

8.2 Attorney Fees

Applicant's Attorney Fees:
Fee Percentage: [___]%
Fee Amount: $[AMOUNT]
☐ Fee is subject to approval by the Workers' Compensation Judge

Defendant's Contribution to Applicant's Attorney Fees (if any): $[AMOUNT]

8.3 Confidentiality (if applicable)

☐ The parties agree that the terms of this settlement shall remain confidential and shall not be disclosed to any third party except as required by law.

☐ No confidentiality provision applies.

8.4 Non-Disparagement (if applicable)

☐ The parties agree not to make any disparaging statements about each other in connection with this claim.

8.5 Return to Work

Employment Status:
☐ Applicant has returned to work with same employer
☐ Applicant has returned to work with different employer
☐ Applicant is not currently working
☐ Applicant is retired

Supplemental Job Displacement Benefit (SJDB):
☐ Applicant has received SJDB voucher
☐ Applicant is entitled to SJDB voucher
☐ SJDB is included in this settlement (C&R only)
☐ SJDB is not applicable

SECTION 9: APPROVAL AND EFFECTIVE DATE

9.1 Requirement of Approval

The parties acknowledge that this settlement is subject to approval by a Workers' Compensation Judge. This settlement shall not be effective until such approval is obtained.

9.2 Hearing Date

Settlement Conference/Approval Hearing:
Date: [DATE]
Time: [TIME]
Location: [ADDRESS]
Judge: [NAME] (if assigned)

☐ Applicant will appear in person
☐ Applicant will appear by telephone
☐ Applicant's appearance is waived

9.3 Effective Date

This settlement shall become effective on the date the Workers' Compensation Judge signs the Order Approving Compromise and Release or the Findings and Award.

SECTION 10: SIGNATURES

10.1 Applicant Signature

I, [APPLICANT NAME], have read this entire settlement agreement. I understand its terms and consequences. I have had the opportunity to consult with my attorney. I agree to be bound by the terms of this settlement and request that it be approved by the Workers' Compensation Judge.

Applicant Signature: _________________________________

Printed Name: [NAME]

Date: [DATE]

10.2 Applicant's Attorney Signature

I, as attorney for Applicant, have reviewed this settlement with my client. I believe this settlement is in my client's best interest and recommend its approval.

Attorney Signature: _________________________________

Printed Name: [NAME]

State Bar Number: [NUMBER]

Date: [DATE]

10.3 Defendant's Attorney Signature

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

Attorney Signature: _________________________________

Printed Name: [NAME]

State Bar Number: [NUMBER]

Date: [DATE]

10.4 Claims Examiner Approval (if required)

Claims Examiner Signature: _________________________________

Printed Name: [NAME]

Title: [TITLE]

Date: [DATE]

SECTION 11: WORKERS' COMPENSATION JUDGE APPROVAL

ORDER APPROVING SETTLEMENT

FOR WORKERS' COMPENSATION JUDGE USE ONLY

Having reviewed the settlement agreement and having examined the Applicant (if required), the undersigned Workers' Compensation Judge finds that:

☐ The settlement is adequate and in the best interest of the Applicant
☐ The Applicant understands the terms and consequences of the settlement
☐ The attorney fees are reasonable
☐ The settlement is approved

IT IS SO ORDERED.

Workers' Compensation Judge Signature: _________________________________

Printed Name: [NAME]

Date: [DATE]

[END OF DOCUMENT]