NOTICE OF SUBROGATION RIGHTS AND LIEN

(Workers' Compensation Employer/Carrier Subrogation Claim)

PART 1: CASE IDENTIFICATION

NOTICE DATE: [DATE]

WORKERS' COMPENSATION CLAIM NUMBER: [NUMBER]

DATE OF INJURY: [DATE]

INJURED WORKER: [NAME]

EMPLOYER: [EMPLOYER NAME]

INSURANCE CARRIER/CLAIMS ADMINISTRATOR: [CARRIER NAME]

PART 2: NOTICE TO INJURED WORKER AND THIRD PARTIES

IMPORTANT NOTICE

TO: [INJURED WORKER NAME]
[INJURED WORKER'S ATTORNEY, IF KNOWN]
[THIRD PARTY / THIRD PARTY'S ATTORNEY / THIRD PARTY'S INSURER]

FROM: [EMPLOYER NAME] and/or [INSURANCE CARRIER NAME]
("Employer/Carrier")

PLEASE TAKE NOTICE that [EMPLOYER NAME] and [INSURANCE CARRIER NAME] hereby assert their subrogation rights and lien against any recovery obtained by [INJURED WORKER NAME] from any third party responsible for the injury that occurred on [DATE OF INJURY].

PART 3: BASIS FOR SUBROGATION CLAIM

3.1 Statutory Authority

This subrogation claim is asserted pursuant to:

☐ California Labor Code Sections 3850-3864
☐ Texas Labor Code Section 417.001 et seq.
☐ New York Workers' Compensation Law Section 29
☐ Florida Statutes Section 440.39
☐ [YOUR STATE]: [CITE STATUTE]

3.2 Third Party Liability

The work injury sustained by [INJURED WORKER NAME] was caused in whole or in part by the negligence or wrongful conduct of a third party, specifically:

Third Party Name: [NAME]

Third Party Address:
[ADDRESS]
[CITY], [STATE] [ZIP]

Third Party's Insurance Carrier (if known): [CARRIER NAME]

Third Party Claim/Policy Number (if known): [NUMBER]

Nature of Third Party's Liability:
[DESCRIBE - e.g., motor vehicle accident caused by third party driver, defective product, premises liability, etc.]

____________________________________________________________________________

____________________________________________________________________________

PART 4: WORKERS' COMPENSATION BENEFITS PAID

4.1 Summary of Benefits Paid to Date

4.2 Estimated Future Benefits

4.3 Total Subrogation Claim

Total Benefits Paid to Date: $[AMOUNT]

Total Estimated Future Benefits: $[AMOUNT]

TOTAL SUBROGATION/LIEN CLAIM: $[TOTAL]

Note: This amount is subject to adjustment as additional benefits are paid.

PART 5: NOTICE OF RIGHTS

5.1 Employer/Carrier Rights

Pursuant to applicable workers' compensation law, Employer/Carrier has the following rights:

☐ Right of Subrogation: The right to bring an action directly against the third party tortfeasor for recovery of workers' compensation benefits paid.

☐ Lien Rights: A lien against any settlement or judgment obtained by the injured worker from the third party.

☐ Right to Intervene: The right to intervene in any lawsuit filed by the injured worker against the third party.

☐ Right to Reimbursement: The right to reimbursement from any third-party recovery, subject to statutory reductions.

☐ Credit Against Future Benefits: The right to a credit against future workers' compensation benefits from the injured worker's net third-party recovery.

5.2 Requirements for Settlement

IMPORTANT: Under [STATE] law:

☐ Neither the injured worker nor the employer/carrier may settle with the third party without the written consent of the other party.

☐ Any settlement or release executed without such consent may be void and unenforceable.

☐ Before settling any claim with the third party, the injured worker must notify the employer/carrier and obtain consent.

PART 6: ALLOCATION OF THIRD-PARTY RECOVERY

6.1 Statutory Formula

Under [STATE] law, any recovery from the third party shall be allocated as follows:

Priority of Payment:

1. First: Reasonable litigation expenses and attorney fees
2. Second: Employer/Carrier's reimbursement for benefits paid (lien)
3. Third: Balance to injured worker

6.2 Attorney Fee Contribution

If the injured worker's attorney obtains a recovery from the third party, the employer/carrier may be required to contribute to attorney fees. The employer/carrier:

☐ Agrees to contribute [___]% toward attorney fees from its recovery
☐ Reserves the right to contest the attorney fee allocation
☐ Will negotiate attorney fee contribution at time of settlement

6.3 Reduction for Comparative Fault

If the employer was partially at fault for the injury, the employer/carrier's subrogation recovery may be reduced in proportion to the employer's percentage of fault.

PART 7: CONTACT INFORMATION

7.1 Employer/Carrier Representative

For questions regarding this subrogation claim, contact:

Subrogation Representative: [NAME]

Company: [INSURANCE CARRIER / TPA / LAW FIRM]

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

Phone: [PHONE NUMBER]

Fax: [FAX NUMBER]

Email: [EMAIL]

7.2 Subrogation Counsel (if applicable)

Attorney Name: [NAME]

Firm: [FIRM NAME]

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

Phone: [PHONE NUMBER]

Email: [EMAIL]

PART 8: REQUESTS AND DEMANDS

8.1 Request for Information

Employer/Carrier requests that the injured worker and/or their attorney provide the following information:

☐ Name and contact information of any attorney retained to pursue the third-party claim

☐ Status of any lawsuit filed against the third party

☐ Copy of any complaint filed against the third party

☐ Notice of any settlement discussions or offers

☐ Notice prior to any settlement with the third party

8.2 Demand for Consent

Employer/Carrier demands that no settlement be made with any third party without first:

1. Providing written notice to Employer/Carrier at least [NUMBER] days before settlement
2. Obtaining written consent from Employer/Carrier
3. Ensuring proper allocation of the settlement proceeds

8.3 Request for Lien Protection

If a third-party lawsuit has been filed, Employer/Carrier requests:

☐ That this Notice be filed with the court
☐ That Employer/Carrier be permitted to intervene in the action
☐ That any judgment or settlement include provision for payment of this lien

PART 9: WARNINGS AND CONSEQUENCES

9.1 Warning to Injured Worker

PLEASE BE ADVISED:

☐ If you settle with the third party without obtaining Employer/Carrier's consent, the settlement may be voidable.

☐ If you receive a third-party recovery without properly allocating funds to Employer/Carrier, you may be personally liable for the full lien amount.

☐ Employer/Carrier may be entitled to a credit against future workers' compensation benefits equal to your net third-party recovery.

☐ Failure to notify Employer/Carrier of settlement may constitute fraud.

9.2 Warning to Third Party/Third Party's Insurer

PLEASE BE ADVISED:

☐ This letter serves as notice of Employer/Carrier's lien against any settlement or judgment.

☐ Any settlement made without satisfaction of this lien may subject the third party or their insurer to separate liability to Employer/Carrier.

☐ Payment to the injured worker without protecting this lien may not discharge your liability to Employer/Carrier.

PART 10: ONGOING LIEN UPDATES

10.1 Updated Lien Statements

Employer/Carrier will provide updated lien statements upon request. The current lien amount is subject to change as additional benefits are paid.

Request updated lien statements from:
[CONTACT NAME]
[EMAIL]
[PHONE]

10.2 Interest

Employer/Carrier reserves the right to claim interest on the lien amount from the date of any third-party settlement or judgment.

PART 11: VERIFICATION

I, [NAME], declare under penalty of perjury that:

☐ I am authorized to assert this subrogation claim on behalf of [EMPLOYER NAME] and/or [INSURANCE CARRIER NAME].

☐ The information contained in this Notice is true and correct to the best of my knowledge.

☐ The benefits itemized herein have been paid to or on behalf of [INJURED WORKER NAME] in connection with the workers' compensation claim arising from the injury of [DATE].

Signature: _________________________________

Printed Name: [NAME]

Title: [TITLE]

Date: [DATE]

PART 12: PROOF OF SERVICE

I declare that on [DATE], I served this Notice of Subrogation Rights and Lien on the following:

Signature: _________________________________

Printed Name: [NAME]

Date: [DATE]

[END OF DOCUMENT]