STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF INDUSTRIAL ACCIDENTS WORKERS' COMPENSATION APPEALS BOARD (See Page 3 for Instructions) THIRD PARTY COMPROMISE AND RELEASE CASE NO. SOCIAL SECURITY NO. (Mr.) (Mrs.) (Miss) vs. EMPLOYEE ADDRESS CORRECT NAME OF EMPLOYER ADDRESS CORRECT NAME OF INSURANCE CARRIER ADDRESS The parties hereto, for the purpose of compromise only, hereby submit the following agreed statements of fact: 1. , born on claims that he was employed on the day of at (MONTH) as a (YEAR) (CITY) (STATE) by then insured as to (OCCUPATION) (NAME OF EMPLOYER) workers' compensation liability by and that (STATE NAME OF CARRIER OR WHETHER SELF-INSURED) he 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 $ wages were $ while the average weekly . 3. The employee's present disability is (STATE PRESENT DISABILITY RESULTING FROM THE INJURY) and the employee returned to work . (IF SO, WHEN) 4. (a) Temporary disability indemnity has been paid to the employee in the sum of $ per week covering (b) to . The amount due and unpaid to the employee is $ Permanent disability indemnity has been paid to the employee in the sum of $ 5. Medical and hospital expenses have been paid $ or carrier. Unpaid bills amount to $ at $ . covering period to by the employee and $ . by the employer . Future medical and hospital expense is estimated at $ . Unpaid and future medical and hospital expense is to be assumed as follows: 6. Name and address of employee's attorney, if any DIA WCAB FORM 17 (PAGE 1) (REV. 11-74) 2002 © American LegalNet, Inc. 7. It is claimed that the injury to the employee was caused by the negligence of . An agreement has been reached for the settlement in full of the employee's claim for personal injury against said alleged tort-feasor for the sum of $ . 8. Copy of the settlement agreement between the employee and the alleged tort-feasor is (COPY MUST BE ATTACHED, IF IN WRITING, OR EXPLANATION GIVEN) 9. From said sum the employee's attorney requests a fee of $ and $ for expenses incurred [Note: attach supporting statements, e.g.: Court approval, agreement, services rendered, etc. -- See Labor Code Section 3860(f)] leaving a balance of $ to be divided between the employee and the as follows: (CARRIER OR SELF-INSURED) To employee (net) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............ $ To (CARRIER OR SELF INSURED) 10. Reason for Compromise (include issues that would be raised in event of proceedings under provisions of paragraph 13) 11. The undersigned request that this Compromise Agreement and Release be approved. 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 causes 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. 13. It is agreed by all parties hereto that the filing of this document is the filing of an application on behalf of the employee, and that the W.C.A.B. may in its 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 the date of filing of this document, and that the W.C.A.B. 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. DIA WCAB FORM 17 (PAGE 2) (REV. 11-74) 2002 © American LegalNet, Inc. 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: for temporary disability covering the period for accrued medical expense paid or incurred by the employee. for future medical care. for permanent disability. $ $ $ $ to . (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.) Witness the execution hereof this day of , , at WITNESSES THE INJURED EMPLOYEE'S SIGNATURE MUST BE ATTESTED BY TWO DISINTERESTED PERSONS OR ACKNOWLEDGED BEFORE A NOTARY PUBLIC STATE OF CALIFORNIA County of ss. On this day of A.D. before me, a Notary Public in and for the 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 above written. Notary Public in and for said County and State of California INSTRUCTIONS 1. If the injured employee be under 18 years of age and a guardian ad litem has not been previously appointed, a petition for appointment of guardian ad litem and trustee must accompany this agreement. 2. The guardian must sign this agreement on behalf of an injured employee who is under 18 years of age. If the minor is above the age of 14, such minor should also sign this agreement. 3. Kindly attach all medical reports not heretofore submitted to the Workers' Compensation Appeals Board. 4. Also attach a copy of the agreement with the third party tort-feasor, if such agreement is in writing. DIA WCAB FORM 17 (PAGE 3) (REV. 11-74) 2002 © American LegalNet, Inc.