WORKERS' COMPENSATION APPEALS BOARD DIVISION OF WORKERS' COMPENSATION DEPARTMENT OF INDUSTRIAL RELATIONS STATE OF CALIFORNIA COMPROMISE AND RELEASE (Dependency Claim) Mr. Mrs. Miss vs. EMPLOYEE CASE NO. SOCIAL SECURITY NO. ADDRESS CORRECT NAME OF EMPLOYER ADDRESS CORRECT NAME OF INSURANCE CARRIER ADDRESS The parties hereto, for the purpose of compromise only, agree as follows: 1. The above-named applicant __ claim____ that (NAME OF EMPLOYEE) while employed at on by by (STATE NAME OF CARRIER OR WHETHER SELF-INSURED) , then insured as to Workers' Compensation liability sustained injury arising out of and in the course of such employment as follows: . 2. 3. 4. 5. The death of said employee occurred on The actual weekly wages of the employee at the time of claimed injury were wages (statutory) were . . Payments of compensation to the employee in his lifetime on account of the claimed injury were The applicant__ herein claim__ to have been dependent upon said employee at the time of claimed injury and state___ the names, ages, relationship to, and the extent of dependency upon said deceased employee to have been as follows: NAME AGE RELATIONSHIP EXTENT OF DEPENDENCY , 20 _____, as a result of the claimed injury. , while average weekly 6. The parties hereby agree to settle any and all claims of said dependent__ on account of the claimed injury and the death of said employee by payment of the sum of $ , payable as follows to: . 7. The parties hereby agree (if such items of expense be claimed) that medical, hospital and burial expense required by reason of the alleged injury and the death of the employee shall be borne as follows: DWC WCAB FORM 16 (PAGE 1) (Rev. 10-92) 2002 © American LegalNet, Inc. 8. 9. The name and address of applicant's attorney (if any): Reason for compromise: 10. The undersigned request that this compromise agreement and release be approved. 11. Upon approval of this compromise agreement as provided by law, and payment in accordance with the provisions of said order of approval, said applicants and each of them do hereby release and forever discharge said employer and said insurance company of and from all claims, demands, actions or causes of action, of every kind or nature whatsoever, on account of, or by reason of the injury and death sustained as aforesaid by the employee, and in particular of any, all and every claim or cause of action which the undersigned, heirs, executors, representatives, or administrators may have had, now have, or shall hereafter have against said employer, said insurance carrier, and each of them under Division 4 of Labor Code of the State of California. 12. It is agreed by all parties hereto that the filing of this document is the filing of an application on behalf of the applicant , and that it may be set 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 the date of filing of this document, and that it may thereafter be approved, disapproved, or a decision issued after a hearing has been held and the matter regularly submitted. 13. For the purpose of determining the lien claim filed herein for the unemployment compensation disability and/or unemployment compensation 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: for temporary disability covering the period to . $ $ for accrued medical expense paid or incurred by the employee. for future medical care. $ $ for permanent disability. (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 the amounts involved.) WITNESS the signature hereof this _______ day of _______________, 20 ______, at _______________________________ WITNESSES THE APPLICANT'S SIGNATURE MUST BE ATTESTED BY TWO DISINTERESTED PERSONS OR ACKNOWLEDGED BEFORE A NOTARY PUBLIC STATE OF CALIFORNIA } SS County of On this ______ day of _____________, A.D., 20 ____, before me, _____________________________________________ a Notary Public in and for said County and State, residing therein, duly commissioned and sworn, personally appeared known to me to be the person___ whose name subscribed to the within Instrument, and acknowledged to me that __he__ executed the same. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal the day and year in this Certificate first written above. _________________________________________________ Notary Public in and for said County and State of California DWC WCAB FORM 16 (PAGE 2) (Rev. 10-92) 2002 © American LegalNet, Inc.