DWC-CA form 10214 (e) (PAGE 1) (REV. 11/2008) STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD THIRD PARTY COMPROMISE AND RELEASE Employee (Completion of this section is required) Employer (Completion of this section is required) Venue Choice is based upon: (Completion of this section is required)Select 3 Letter Office Code For Place/Venue of Hearing (From Document Cover Sheet) Case Number 5 SSN (Numbers Only) Case Number 4 Case Number 3 Case Number 2 Case Number 1 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 MI First Name Last Name Street Address/PO Box (Please leave blank spaces between numbers, names or words) City Zip Code City Address/PO Box (Please leave blank spaces between numbers, names or words) Name (Please leave blank spaces between numbers, names or words) State State DWC-CA form 10214 (e) (PAGE 2) (REV. 11/2008) Applicant's Attorney or Authorized Representative: Defendant's Attorney or Authorized Representative: Zip Code State Law Firm Name Firm Number Last Name First Name City Zip Code State City Law Firm Name Firm Number Last Name First Name Law Firm/Attorney Non Attorney Representative Street Address/PO Box (Please leave blank spaces between numbers, names or words) Zip Code State City Insurance Carrier Name (Please leave blank spaces between numbers, names or words)Insurance Carrier Information (If applicable - include even if carrier is adjusted by claims administrator) Address/PO Box (Please leave blank spaces between numbers, names or words) Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) Non Attorney Representative Law Firm/Attorney DWC-CA form 10214 (e) (PAGE 3) (REV. 11/2008) Claims Administrator Information (If applicable)to workers' compensation liability byThe parties hereto, for the purpose of compromise only, hereby submit the following agreed statements of fact: as a(n)byMM/DD/YYYY(State present disability resulting from injury)(If so when) per week covering to tocovering period from Zip Code State City Street Address/PO Box (Please leave blank spaces between numbers, names or words) Name (Please leave blank spaces between numbers, names or words) born on 1. claims that he was employed on the (Month) (Year)day of,at (city), (Occupation) (Name of employer) (State name of carrier or whether self insured) sustained an injury arising out of and in the course of his employment as follows: 2. The actual weekly wages of the employee at the time of injury were $ while the average weekly wages were $ 3. The employee's present disability is and the employee returned to work 4. (a) Temporary disability indemnity has been paid to the employee in the sum of $ at $ MM/DD/YYYY MM/DD/YYYY the amount due and unpaid to the employee is $ (b) Permanent disability indemnity has been paid to the employee in the sum of $ MM/DD/YYYY MM/DD/YYYY Statethen insured as ....,, DWC-CA form 10214 (e) (PAGE 4) (REV. 11/2008)8. Copy of settlement agreement between employee and the alleged tort-feasor is attached. 6. Name and address of employee's attorney, if any for expenses incurred [Note attach supporting statements, e.g. Court agreement, services rendered, etc. See Labor Code to be divided between the employee and the(Carrier or Self insured). 5. Medical and hospital expenses have been paid $ by the employee and $ by employer or carrier. Unpaid bills amount to $Future medical and hospital expense. is estimated at $ .Unpaid and future medical and hospital expense is to be assumed as follows: Law Firm or Company Name (If Applicable) Attorney/Rep First Name MI Attorney/Rep Last Name Address/PO Box (Please leave blank spaces between numbers, names or words) Suite/Apt# Zip Code State City 10. Reason for compromise (include issues that would be raised in event of proceedings under provisions of paragraph 13) 7. It is claimed that the injury to the employee was caused by the negligence of Yes No (Copy must be attached if in writing, or explanation given) Court approval documents attached . To Employee $ To: 9. From said sum the employee's attorney requests a fee of $ and $ section 3860(f)] leaving a balance of $ (Carrier or Self insured) . to carrier or self insured employer $. An agreement has been reached for settlement in full of the employee's claim for personal injury against said alleged tort-feasor for the sum of $ 12. Upon approval of this Compromise Agreement by the Workers' Compensation Appeals Board and payment in accordance with the provisions hereof, said employee releases and forever discharges said employer and insurance carrier from all claims and cause of action, whether now known or ascertained, or which may hereafter arise or develop as a result of said injury, including any and all liability of said employer and said insurance carrier and each of them to the dependents, heirs, executors, representatives, administrators or assigns of said employee.DWC-CA form 10214 (e) (PAGE 5) (REV. 11/2008)11. The undersigned request that this compromise Agreement and Release be approved.THE APPLICANT'S (EMPLOYEE'S) SIGNATURE MUST BE ATTESTED TO BY TWO DISINTERESTED PERSONS OR ACKNOWLEDGED BEFORE A NOTARY PUBLICBy signing this agreement, applicant (employee) acknowledges that he/she has read and understands questions he/she may have had about this agreement answered to his/her satisfaction.Witness the signature hereof this day of , at Witness 1 (Date)Applicant (Employee)(Date) Witness 2(Date)Attorney for Applicant(Date) Interpreter(Date)Attorney for Defendant(Date)(Date) 13. It is agreed by all parties hereto that the filing of this document is the filing of an application on behalf of employee and that the workers' compensation administrative law judge may in his or her discretion set the matter for hearing as a regular application, reserving to the parties the right to put in issue any of the facts admitted herein, and that if hearing is held with this document used as an application the defendants shall have available to them all defenses that were available as of date of filing of this document, and that the workers' compensation administrative law judge may thereafter either approve said Compromise Agreement and Release or disapprove the same and issue Findings and Award after hearing has been held and the matter regularly submitted for decision.14. For the purpose of determining the lien claim filed herein for the unemployment compensation disability benefits or unemployment compensation benefits and extended duration benefits which have been paid under or pursuant to the California Unemployment Insurance Code, the parties propose the following division of the sum agreed upon for settlement and release of this case.(The above segregation must be fair and reasonable and must be based on the real facts of the case. There should be no attempt made to deprive the lien claimant of a reasonable recovery consistent with all the amounts involved. W.C.A.B Rule 10886 requires proof of service of a copy of this agreement on such lien claimant.)$$$$ toAttorney for Defendant for temporary disability covering the period for accrued medical expense paid or incurred by the employee. for future medical care. for permanent disability. . DWC-CA form 10214 (e) (PAGE 6) (REV. 11/2008)ACKNOWLEDGMENT State of California County of ) On before me, (insert name and title of the officer) personally appeared , who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature (Sea