STATE OF MARYLAND WORKERS’ COMPENSATION COMMISSION 10 E. BALTIMORE STREET, BALTIMORE, MD 21202 410-864-5100 ● Email: info@wcc.state.md.us ● Web: http://www.wcc.state.md.us Claim Number: Employee/Claimant: Employer: Insurer: AGREEMENT OF FINAL COMPROMISE AND SETTLEMENT THIS AGREEMENT has been made on this between day of ,20 , by and , the Claimant, , the Employer, and the Insurer of the Employer, under the Workers’ Compensation Law of Maryland. The parties acknowledge that the Claimant has filed a claim with the Workers’ Compensation Commission of Maryland (the Commission) to recover workers’ compensation benefits for alleged disability resulting from accidental personal injury or disablement from occupational disease arising out of and in the course of his or her employment with the Employer, which injury or disablement is alleged to have occurred on or about the day of , 20 ; and The Employer and Insurer deny the allegations of the Claimant, either in whole or in part, so that there now exists a dispute between the Claimant on the one hand and the Employer and Insurer on the other, as to whether the Claimant is entitled to any workers’ compensation benefit and/or, if so entitled, as to the nature and extent of disability involved and the benefits or additional benefits to be paid or provided; and Irrespective of any and notwithstanding the divergent views held by the parties concerning the occurrence of the accidental personal injury or disablement, the nature and extent of disability resulting therefrom, the workers’ compensation benefits allowable therefore, and all other benefits or rights that any of the parties to the claim might or could have in the premises, the said parties have reached an agreement providing, subject to the approval of the Commission, for a final compromise and settlement of any and all claims which the Claimant or his or her personal representative or beneficiaries might now or could hereafter have under the provisions of the Workers’ Compensation Law against the Employer and/or the Insurer. ACCORDINGLY, it is hereby agreed as follows: 1. The Employer and the Insurer hereby agree to pay the Claimant the sum of in addition to compensation previously paid. 2. The Employer and the Insurer do hereby agree to pay all causally related medical expenses pursuant to the medical fee guide up to the date of this agreement. MD WCC H-09 3/31/06 American LegalNet, Inc. www.FormsWorkflow.com 3. The parties agree as additional term(s) of this agreement: (Structured settlement to be attached) 4. The parties certify that this agreement satisfies all the conditions under 42 CFR 411.46 (Medicare Regulation), and, if applicable, all supporting documentation is attached and incorporated into this agreement. THE PARTIES AGREE THAT PENDING THE APPROVAL BY CMS ( MEDICARE) OFTHE SET ASIDE AGREEMENT, THE EMPLOYER AND INSURER WILL PAY ALL CAUSALLY RELATED MEDICAL EXPENSES PER THE FEE GUIDE. 5. If this agreement included the compromise of any statutory liens following the settlement of a third party action, the release and documentation as to the distribution of the third party settlement proceeds is attached. The terms of this settlement include the payment of $ to the Self Insured Employer or the Employer and the Insurer in full satisfaction of their statutory lien of $ . 6. The Claimant hereby accepts this Agreement and the aforesaid payment(s) in final compromise and settlement of any and all Claims which the Claimant, his or her personal representative, dependents, wife and children or any other parties who might become beneficiaries under the Workers’ Compensation Law, might now or could hereafter have under the provision of the said Law, arising out of the aforesaid injury or disablement or the disability resulting therefrom, and does hereby, on behalf of himself or herself and all of said other parties, release and forever discharge the Employer and Insurer, their personal representative, heirs, successors and assigns, from all other claims of whatsoever kind which might or could hereafter arise under the Law from the said injury, disablement or disability. 7. The claimant’s attorney is requesting a fee of $ for legal services and the sum of $ as reimbursement for expenses. Doctor is requesting a fee of $ for medical services (note: an itemized doctor’s bill must accompany the settlement papers). If the settlement is approved, payment of both fees is deducted from the amount of the settlement of $ leaving the claimant a net balance of $ . 8. This Agreement is made subject to the approval of the Commission, and when so approved shall immediately become effective and binding upon all of the parties hereto. ATTEST: Attorney for Claimant (Signature) Claimant (Signature) Employer, and Insurer Attorney for Employer/Insurer (Signature) MD WCC H-09 3/31/06 American LegalNet, Inc. www.FormsWorkflow.com