State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC(DO)-370 Interactive(r. 4/24/13) NAME: ORDER APPROVING SETTLEMENT WITH DISMISSAL N.J.S.A. 34:15-20 CASE NO'S.: VICINAGE: FEDERAL EMPLOYER NUMBER PETITIONER MEDICARE ELIGIBLE: ADDRESS: YES NO ATTORNEY FOR PETITIONER INSURANCE CARRIER DATE OF BIRTH: NAME: ADDRESS: RESPONDENT vs NAME: ADDRESS: TELEPHONE NUMBER (AREA CODE): APPEARING: NAME ADDRESS: SELF-INSURED TPA ATTORNEY FOR RESPONDENT NAME: ADDRESS: CLAIM NUMBER: TELEPHONE NUMBER (AREA CODE): APPEARING: This is a lump sum settlement between the parties in the amount of $ pursuant to N.J.S.A. 34:15-20 which has the effect of a dismissal with prejudice, being final as to all rights and benefits of the petitioner and is a complete and absolute surrender and release of all rights arising out of this/these claim petitions(s). The payment hereunder shall be recognized as a payment of workers' compensation benefits for insurance rating purposes only. The parties agree that this settlement [ does (complete page 2) / does not] contemplate a complete and absolute surrender and release of any and all rights by the petitioner's dependents as defined by N.J.S.A. 34:15-13 arising out of this/these claim petition(s). Order for Child Support Attached Addendum attached Further Agreed: ALLOWANCES MEDICAL FEE ALLOWED: (report and/or testimony) REIMBURSE TAX IDENTIFICATION NUMBER TOTAL AMT. ALLOWED PAYABLE BY PETITIONER PAYABLE BY RESPONDENT ATTORNEY(S) FEE: STENOGRAPHIC SERVICE: MISCELLANEOUS FEES: Reason(s) for Section 20 (check all that apply): Contested issues regarding: JURISDICTION WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT OF COPY: LIABILITY CAUSAL RELATIONSHIP DEPENDENCY After considering the circumstances, I find this settlement fair and just. PETITIONER'S ATTORNEY JUDGE OF COMPENSATION DATE PETITIONER (where applicable) RESPONDENT'S ATTORNEY JUDGE'S NAME THE ORIGINAL OF THIS DOCUMENT, SIGNED BY THE JUDGE OF COMPENSATION, WILL BE MAINTAINED ON FILE IN THE DIVISION OF WORKERS' COMPENSATION, PURSUANT TO N.J.S.A. 34:15-121 et. seq. American LegalNet, Inc. www.FormsWorkFlow.com State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC(DO)-370 Interactive(r. 4/24/13) ORDER APPROVING SETTLEMENT WITH DISMISSAL N.J.S.A. 34:15-20 Page 2 CASE NO'S.: VICINAGE: The parties agree that this settlement does contemplate a complete and absolute surrender and release of any and all rights by the petitioner's dependents as defined by N.J.S.A. 34:15-13 arising out of this/these claim petitioner(s). As the spouse or other person who may be defined as a dependent under N.J.S.A. 34:15-13 or the guardian or representative of such a person, I (we) consent to the entry of this order and recognize that this agreement is a complete and absolute surrender of any rights that I (we) may have pursuant to N.J.S.A. 34:15-13, should petitioner die as a result of the injuries, conditions, or exposures alleged in this/these claim petition(s). Name Date Name Date On Behalf of On Behalf of Name Date Name Date On Behalf of On Behalf of Name Date Name Date On Behalf of On Behalf of I certify that the above is (are) the only individual(s) who is (are) dependent(s) as defined in N.J.S.A. 34:15-13 at the present time. _________________________________________________________ Petitioner Date WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT OF COPY: After considering the circumstances, I find this settlement fair and just. PETITIONER'S ATTORNEY JUDGE OF COMPENSATION DATE PETITIONER (where applicable) JUDGE'S NAME THE ORIGINAL OF THIS DOCUMENT, SIGNED BY THE JUDGE OF COMPENSATION, WILL BE MAINTAINED ON FILE IN THE DIVISION OF WORKERS' COMPENSATION, PURSUANT TO N.J.S.A. 34:15-121 et. seq. RESPONDENT'S ATTORNEY American LegalNet, Inc. www.FormsWorkFlow.com