GENERAL RELEASE the undersigned Employee/Claimant, hereinafter I referred to as Releasor, for and in consideration of the sum of $ , as indemnity benefits, $ which shall be allocated as follows: $ as future medical costs, $ as attorney’s fees, and $ as costs to be received from or on behalf of Employer and Carrier , hereinafter referred to as Releasees, voluntarily and knowingly enter into this Agreement as follows: I hereby do, upon payment of the consideration set forth above, forever release the above-mentioned Releasees from any and all claims, known and unknown, Releasor has or may have against Releasees as of the date of execution of this General Release, including, but not limited to, any and all liability for the payment or provision of any class of benefits, of whatever kind or classification available under the Florida Workers’ Compensation Law or that of any other state of the United States because of the Releasor’s alleged work-related accident of on or about or any other known or unknown work-related injury whether undiscovered or not reasonably discoverable or not matured or which may have already occurred or developed or may be latent or may in the future occur or develop that Releasor may have sustained while employed by the Releasees, and all other claims and causes of action and potential claims and causes of action. The Releasor represents and affirms that all accidents, injuries, and occupational diseases known to have occurred or have been sustained while employed by the Employer have been revealed. Additionally, Releasor voluntarily withdraws all pending claims with prejudice. Releasor understands that he/she is hereby relinquishing the right to have any resolved claims, conflicts or disputes heard and decided by the Judge of Compensation Claims. Releasor represents to Releasees that he/she and his/her attorneys alone are entitled to the settlement funds and that there are no liens or claims made upon these funds by any other party (except an arrearage in Child Support in the amount of $ ). Releasor hereby acknowledges, understands and agrees that Releasees shall only remain liable for payment to authorized medical providers for treatment rendered for the compensable injury(ies) through the date the Judge of Compensation Claims enters the Order Approving the Motion for Attorney’s Fee and Child Support Allocation. The Releasees shall be solely responsible for the payment to any and all authorized medical providers for medical treatment/expenses incurred up to the date the Judge signs the Order approving the Motion for Attorney’s Fee and Child Support Allocation. (optional) The authorized medical providers referred to in the preceding paragraph are: 1 American LegalNet, Inc. www.FormsWorkflow.com Releasor hereby agrees to indemnify and hold harmless the Releasees from any and all claims, liens, and subrogated interests herein for which these funds are or may be intended. It is specifically understood by and between the Releasor and Releasees that this Release is in no way to be construed as an admission of any wrongdoing or liability on the part of the Releasees. It is expressly warranted by Releasor that no promise or inducement has been offered except as set forth herein; that this Release is executed without reliance on any statement of the Releasees, or their representatives, concerning the nature and extent of the injury(ies), claims of lien and/or legal liability thereof, and that Releasor has fully discussed the terms and significance of this Release with the attorney of their choice and has made the informed, knowing and voluntary decision to execute this Release. The Releasor represents that the terms and conditions of this settlement agreement have been completely read and explained to him by his attorneys and that those terms are fully understood and are voluntarily accepted by him. The Releasor acknowledges and agrees that this Release contains the entire agreement among the parties hereto, and that the terms of this Release are contractual and binding, not merely a recital. Any modification of this Release must be in writing and signed by both Releasor and Releasees. Releasor acknowledges and agrees that this Release shall not be subject to modification. Releasor further understands and agrees that this Release of All Claims shall be construed and interpreted in accordance with the laws of the State of Florida. Should any Court deem any portion or provision of this Release null or void, the remainder of the Release shall remain in full force and effect. Releasee does/does not waive its subrogation rights under § 440.39. In reaching this agreement, the parties have, pursuant to § 440.15 Florida Statutes, considered the present value of all future payments of monetary compensation, impairment benefits and death benefits potentially payable to the Releasor on account of the accident referenced herein. In arriving at the stipulated settlement amount, the parties have taken into consideration the Releasor's age of , his/her life expectancy of years as established by the United States Life Tables published by the U. S. Department of Health and Human Services and have also used the statutory eight (8) percent discount rate tables. Consideration was also given to the possible loss of supplemental benefits due under § 440.15 Florida Statutes and to the right of the Social Security Administration to offset disability benefits payable under Florida law. The present value of the future compensation herein was discounted sufficiently to take into consideration the Releasees’ right to offset compensation benefits due under the Florida Workers' Compensation Act against benefits payable in the past and/or future, on account of total disability under Chapter 42 of the United States Code. Specifically, the parties stipulate that in arriving at the amount of the lump sum settlement, the parties have recalculated the Releasor's weekly compensation rate to be $ . This amount was arrived at by dividing the net workers' compensation lump sum settlement of $ by the Releasor's life expectancy of weeks. In reaching this agreement, the parties have considered that many common medical expenses are not paid or reimbursable under the Federal Medicare program. 2 American LegalNet, Inc. www.FormsWorkflow.com These medical expenses are the responsibility of the Releasees’ and are being taken into consideration in the settlement of future medical. These expenses include travel expenses, nonprofessional attendant care, rehabilitation expenses, routine follow-up visits, supporting devices, medical comfort services, Medicare Hospital deductible and Medicare part B co-payments, emergency room treatment and hospitalization not covered by Medicare but necessary in the ongoing treatment of the workers’ compensation injury. It is the intent of the parties that future medical expenses in the amount of shall be utilized by the Releasoor for these non-covered services. This payment is equal to $ per week, representing those services not covered by Medicare brought forward in one lump sum. This sum is to be for the next years into the future, representing the Releasor’s life expectancy. The parties agree that a Medicare Set Aside Agreement (MSA) is/is not required. If an MSA is necessary, the parties shall execute all documents required to obtain CMS approval of the MSA. This agreement is/is not binding on the parties until CMS approves of the MSA. days The Releasees shall pay the consideration for this Release within of the date the Judge of Compensation Claims mails the Order approving the Motion for Attorney’s Fee and Child Support Allocation. Additional terms: Releasor Attorney for Releasor Authorized representative of Releasees 3 American LegalNet, Inc. www.FormsWorkflow.com