STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD COMPROMISE AND RELEASE Employee(Completion of this section is required) Select 3 Letter Office Code For Place/Venue of Hearing (From Document Cover Sheet) DWC-CA form 10214 (c) (Rev. 11/2008) (Page 1 of 9) Employer Information (Completion of this section is required)Venue Choice is based upon: (Completion of this section is required) Zip Code City Address/PO Box (Please leave blank spaces between numbers, names or words) Last Name First Name MI Case Number 1 Case Number 2 Case Number 3 Case Number 4 Case Number 5 SSN (Numbers Only) County of residence of employee (Labor Code section 5501.5(a)(1) or (d).) County where injury occurred (Labor Code section 5501.5(a)(2) or (d).) County of principal place of business of employees attorney (Labor Code section 5501.5(a)(3) or (d).) Zip Code City Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) Employer Name (Please leave blank spaces between numbers, names or words) Insured Self-Insured Legally Uninsured Uninsured State State Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by claims administrator) DWC-CA form 10214 (c) (Rev. 11/2008) (Page 2 of 9) Applicant's Attorney or Authorized Representative: Zip Code City Address/PO Box (Please leave blank spaces between numbers, names or words) Law Firm Name Law Firm Number First Name Law Firm/Attorney Non Attorney Representative Last Name Law Firm/Attorney Non Attorney Representative Zip Code City Address/PO Box (Please leave blank spaces between numbers, names or words) Law Firm Name Law Firm Number Last Name First Name Zip Code City Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) Insurance Carrier Name (Please leave blank spaces between numbers, names or words) State Defendant's Attorney or Authorized Representative: State State Claims Administrator Information (if known and if applicable) IT IS CLAIMED THAT: , alleges that while employed as a(n)1. The injured employee, born(State with specificity the date(s) of injury(ies) and what part(s) of body, conditions or systems are being settled.) ,(Street Address/PO Box - Please leave blank spaces between numbers, names or words).(If Specific Injury, use the start date as the specific date of injury) Body parts, conditions and systems may not be incorporated by reference to medical reports.DWC-CA form 10214 (c) (Rev. 11/2008) (Page 3 of 9) (OCCUPATION AT THE TIME OF INJURY) (DATE OF BIRTH: MM/DD/YYYY) The injury occurred at City Zip Code Zip Code City Street Address/PO Box (Please leave blank spaces between numbers, names or words) Name (Please leave blank spaces between numbers, names or words) (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) Specific Injury Cumulative Injury Case Number 1 State State , sustained injury arising out of and in the course of employment at the locations and during the dates listed below: Body Part 3: Body Part 2: Body Part 4: Body Part 1: Other Body Parts: ,(Street Address/PO Box - Please leave blank spaces between numbers, names or words).(If Specific Injury, use the start date as the specific date of injury),(Street Address/PO Box - Please leave blank spaces between numbers, names or words).(If Specific Injury, use the start date as the specific date of injury),(Street Address/PO Box - Please leave blank spaces between numbers, names or words).(If Specific Injury, use the start date as the specific date of injury)DWC-CA form 10214 (c) (Rev. 11/2008) (Page 4 of 9)Body parts, conditions and systems may not be incorporated by reference to medical reports.Body parts, conditions and systems may not be incorporated by reference to medical reports.Body parts, conditions and systems may not be incorporated by reference to medical reports. Zip Code State City The injury occurred at (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Specific Injury Cumulative Injury Case Number 2 Zip Code State City The injury occurred at (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Specific Injury Cumulative Injury Case Number 3 Zip Code State City The injury occurred at (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Specific Injury Cumulative Injury Case Number 4 Body Part 1: Body Part 2: Body Part 3: Body Part 4: Body Part 4: Body Part 1: Body Part 2: Body Part 3: Body Part 4: Body Part 1: Body Part 3: Body Part 2: Other Body Parts: Other Body Parts: Other Body Parts: ,(Street Address/PO Box - Please leave blank spaces between numbers, names or words).(If Specific Injury, use the start date as the specific date of injury)3. This agreement is limited to settlement of the body parts, conditions, or systems and for the dates of injury set forth in Paragraph No. 1 and further explained in Paragraph No. 9 despite any language to the contrary elsewhere in this document or any addendum. 2. Upon approval of this compromise agreement by the Workers' Compensation Appeals Board or a workers' compensation administrative law judge and payment in accordance with the provisions hereof, the employee releases and forever discharges the above-named employer(s) and insurance carrier(s) from all claims and causes of action, whether now known or ascertained or which may hereafter arise or develop as a result of the above-referenced injury(ies), including any and all liability of the employer(s) and the insurance carrier(s) and each of them to the dependents, heirs, executors, representatives, administrators or assigns of the employee. Execution of this form has no effect on claims that are not within the scope of the workers' compensation law or claims that are not subject to the exclusivity provisions of the workers' compensation law, unless otherwise expressly stated.5. Unless otherwise expressly ordered by the Workers' Compensation Appeals Board or a workers' compensation administrative law judge, approval of this agreement does not release any claim applicant may have for vocational rehabilitation benefits or supplemental job displacement benefits.4. Unless otherwise expressly stated, approval of this agreement RELEASES ANY AND ALL CLAIMS OF APPLICANT'S DEPENDENTS TO DEATH BENEFITS RELATING TO THE INJURY OR INJURIES COVERED BY THIS COMPROMISE AGREEMENT. The parties have considered the release of these benefits in arriving at the sum in Paragraph 7. Any addendum duplicating this language pursuant to Sumner v WCAB (1983) 48 CCC 369 is unnecessary and shall not be attached.6. The parties represent that the following facts are true: (If facts are disputed, state what each party contends under Paragraph No. 9.)(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)Unless otherwise specified herein, the employer will pay no medical expenses incurred after approval of this agreement.DWC-CA form 10214 (c) (Rev. 11/2008) (Page 5 of 9)(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)Body parts, conditions and systems may not be incorporated by reference to medical reports. EARNINGS AT TIME OF INJURY $ Weekly Rate $ TEMPORARY DISABILITY INDEMNITY PAID PERMANENT DISABILITY INDEMNITY PAID Weekly Rate $ TOTAL MEDICAL BILLS PAID $ Total Unpaid Medical Expense to be Paid By: Zip Code State City The injury occurred at (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Specific Injury Cumulative Injury Case Number 5 Period(s) Paid Period(s) Paid End date Body Part 1: Body Part 2: Body Part 3: Body Part 4: Other Body Parts: DWC-CA form 10214 (c) (Rev. 11/2008) (Page 6 of 9)$ for temporary disability indemnity overpayment, if any. requested as applicant's attorney's fee., after deducting the amounts set forth above and lessfurther permanent disability advances made after the date set forth above. Interest under Labor Code section 5800 is included if the sums set forth herein are paid within 30 days after the date of approval of this agreement.7. The parties agree to settle the above claim(s) on account of the injury(ies) by the payment of the SUM OFThe following amounts are to be deducted from the settlement amount: Settlement Amount $ $ $ $ $ $ $ LEAVING A BALANCE OF $ 8. Liens not mentioned in Paragraph No. 7 are to be