Claim Number: IC-10 Page 1 of 2 An Equal Opportunity Employer and Service ProviderTimely, impartial resolution to workers222 compensation appealsOIC-1084 Rev. (05.19) This agreement entered into this day of 20 , by and between ,and , in the state of .The Injured Worker, while working for the Employer, received work-related injuries on or about which resulted in a claim being filed by Injured Worker for the payment of Workers' Compensation benefits and medical services, being claim # , which has been allowed for the following conditions: Address on application is new After filing of the original claim, Injured Worker filed an application for additional award for violation of specific safety requirement(s) on claiming that Employer violated one or more requirement(s) of the specific safety requirements of the Ohio Industrial Commission and/or the Bureau of Workers' Compensation, and that such violation resulted in his/her injury as allowed above, andThe parties now desire to make a full and complete lump sum settlement of the Injured Workers' application, subject to the approval of the Industrial Commission, as follows;Employer promises and agrees to pay Injured Worker a lump sum of $ , and Injured Worker agrees to accept said sum of $ from Employer in full and complete settlement and satisfaction of Injured Worker's application for an additional award of benefits because of the claimed violation of a specific safety requirement(s) based on injuries sustained on or about .Injured Worker agrees and understands that by accepting this lump sum payment, he/she releases and forever discharges Employer, the Industrial Commission, the Bureau of Workers' Compensation and the Ohio State Workers' Compensation Insurance Fund from any and all claims or demands, present or future, that might otherwise be made against Employer because of Employer's claimed violation of a specific safety requirement. Injured Worker Information Name Name Address Address City, State, Zip City, State, Zip Employer222s Representative Information Name Name Injured Worker222s Representative Information Telephone Fax Telephone Fax Telephone Fax Telephone Fax Rep ID# Rep ID# Employer Information (Injured Worker222s Name) (Employer222s Name) (mm/dd/yyyy) (Claim Number) (mm/dd/yyyy) American LegalNet, Inc. www.FormsWorkFlow.com IC-10 Page 2 of 2 An Equal Opportunity Employer and Service ProviderTimely, impartial resolution to workers222 compensation appealsOIC-1084 Rev. (05.19) Injured Worker222s SignatureDate Injured Worker shall sign or cause to be signed such other instruments including a receipt and release, as may be necessary to complete this settlement agreement. This agreement shall be submitted to the Industrial Commission of Ohio for approval, and Employer shall not pay the agreed amount until this agreement shall have been approved by the the Industrial Commision and made a matter of record in the Claim.# . This agreement to settle the claimed safety violation is not an admission of responsibility by the Employer.Nothing in this agreement shall be construed to settle or release Injured Worker's claim for regular Workers' Compensation benefits to which he may be lawfully entitled for injuries he received on or about . This agreement is not intended to change any other legal relationships between Injured Worker and Employer. It is the intention of the parties that this settlement cover only the application for additional benefits because of the claimed violation of a specific safety requirement which Injured Worker filed on .(mm/dd/yyyy) (mm/dd/yyyy) WAIVER Both Injured Worker and Employer have a right to a hearing on this agreement, and are also entitled to a full and complete investigation of the facts and circumstances of the claimed violation. By signing below, both Injured Worker and Employer waive this hearing and notice of hearing, and request immediate end of any investigation now in progress. Witnesses SignatureDateEmployer222s SignatureDateWitnesses SignatureDateThe parties have signed this agreement at the time and place stated. Claim Number: (Claim Number) American LegalNet, Inc. www.FormsWorkFlow.com