NCIC-T-3 03/2019 PAGE 1 OF 1 FORM T-3 ATTORNEYS: FILE WITH AN IC FILE NUMBER VIA EDFP HTTP://WWW.IC.NC.GOV/DOCFILING.HTML OR IF NO IC FILE NUMBER, FOLLOW PLAINTIFF FILING OPTIONS. PLAINTIFFS: EMAIL TO: DOCKETS@IC.NC.GOV MAIL TO: INDUSTRIAL COMMISSION CLERK222S OFFICE 1236 MAIL SERVICE CENTER RALEIGH, NC 27699-1236 VIA HAND DELIVERY: BUSINESS DAYS FROM 8 AM - 5 PM DOBBS BUILDING 430 NORTH SALISBURY STREET RALEIGH, NC 27603 North Carolina Industrial Commission IC File # TA- N.C. Prisoner No.- RELEASE OF TORT CLAIM (G.S. 143-291 ET SEQ.) (if applicable) KNOW ALL MEN BY THESE PRESENTS, That I, We, for the sole consideration of $ to be paid by (Name of Defendant) the payment whereof being made under the provision of G.S. 247 143-291 et seq., I, we, have released, and discharged and by these presents do for myself, ourselves, my, our heirs, executors, administrators and assigns release and forever discharge the its officers, employees, servants and agents of and from any and all claims, demands, damages, actions, cause of action of whatever kind or nature, on account of an accident which occurred on or about the day of , at resulting in (briefly describe injuries and/or damages) I, We, understand that this release is made as compromise to avoid expense and to terminate all controversy and/or claims for injuries or damages of whatever nature, known or unknown, including future developments thereof, in any way growing out of or connected with said accident. I, We, agree that the sum paid is solely by way of compromise of a disputed claim, and it is therefore specifically agreed that this release shall be a complete bar to all claims or suits for injuries or damages of whatsoever nature resulting or to result from said accident. I, We, further understand that until this release is approved by the Industrial Commission and payment has been received by the claimant, that this release will not become effective. IN WITNESS THEREOF I, We, have hereunto set my, our hand(s), this day of , Witness Claimant Witness Address AGREED TO: Unit, Agency or Department By: APPROVED: Defendant222s Attorney The foregoing settlement is hereby approved this day of , By: Commissioner FILE TWO COMPLETE COPIES WITH THE INDUSTRIAL COMMISSION American LegalNet, Inc. www.FormsWorkFlow.com