DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION COMPROMISE AND RELEASE002 AGREEMENT BY STIPULATION002 PURSUANT TO SECTION 449 OF THE002 WORKERS222 COMPENSATION ACT002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER -- DATE OF INJURY WCAIS CLAIM NUMBER X X X X X--EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County TelephoneNOTICE: SUBMIT TO THE ASSIGNED WORKERS222 COMPENSATION JUDGE. TO THE EXTENT THIS AGREEMENT REFERENCES AN INJURY FOR WHICH LIABILITY HAS NOT BEEN RECOGNIZED BY AGREEMENT OR BY ADJUDICATION, THE TERM 223INJURY224 AS USED IN THIS AGREEMENT SHALL MEAN 223ALLEGED INJURY.224 223FUND224 SHALL MEAN THE UNINSURED EMPLOYERS GUARANTY FUND (UEGF), SUBSEQUENT INJURY FUND (SIF), SELF-INSURANCE GUARANTY FUND (SIGF) OR THE PREFUND ACCOUNT OF THE SELF-INSURANCE GUARANTY FUND. MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN INSURER, FUND or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN NAIC code or Insurer code Insurer/TPA claim # This is an agreement in the case of the above listed employee and the above listed employer, insurer, Fund or third party administrator in regards to an injury or occupational disease under the Workers222 Compensation Act only.1.State the date of injury or occupational disease. --MM DD YYYY 2.State the average weekly wage of the employee, as calculated under Section 309. $. /wk3.State the weekly compensation rate paid or payable. $. /wk4.State the precise nature of the injury and whether the disability is total or partial. death. Wage Loss: $ . Medical: $ . American LegalNet, Inc. www.FormsWorkFlow.com Yes No Yes No Yes No If yes, complete and attach a Death Claim Supplement.10.Summarize all wage loss, and to be paid in conjunction with this Compromise and Yes NoIf yesemployer or insurer. Yes No Judges, Rule 131.111(c), must be submitted into evidence as required by Act 109 of 2006 and in the mannerprescribed by the adjudicating Workers222 Compensation Judge.insurance, Medicare, Medicaid, etc. American LegalNet, Inc. www.FormsWorkFlow.com 003003Medicare in accordance with the Medicare Secondary(c) Manner in which conditional payments003003 --by . A copy of this report must be attached. -OR- 16.003 State the issues17.003 A copy of the fee agreement between employee and counsel must be attached.18.003 Litigation costs in the total amount of $. shall be the responsibility of . 19.003 State additional terms and provisionsREMINDER TO PARTIES: Upon approval of the agreement, please promptly withdraw all appeals which are also resolved by this agreement. American LegalNet, Inc. www.FormsWorkFlow.com EMPLOYEE222S CERTIFICATION002003003Pennsylvania Workers222 Compensation Act only.003003Act for the injury.3.003 003003Compensation Act. (Employee222s initials)-OR-I have notrepresent me. (Employee222s Initials)003003compensation claim under the Pennsylvania Workers222 Compensation Act only, and is not considered an admission of liability byemployer and/or insurer and/or administrator and/or Fund.DO NOT SIGN THIS DOCUMENT UNLESS YOU UNDERSTAND THE FULL LEGAL SIGNIFICANCE OF THIS AGREEMENT MM DATEDD YYYY --all petitions are . A list of any petitions or issues that remain open after approval of the Compromise Notary Public THE COMPROMISE AND RELEASE AGREEMENT IS NOT VALID AND BINDING UNLESS APPROVED BY A WORKERS222 COMPENSATION JUDGE WHOSE ROLE IS TO DETERMINE THAT THE EMPLOYEE UNDERSTANDS THE FULL LEGAL SIGNIFICANCE OF THIS AGREEMENT. Employer Information Claims Information Services Email Services Hearing Impaired *755*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com