VIRGINIA: IN THE WORKERS' COMPENSATION COMMISSION ___________________, Claimant v. VWC File No.: ____________ ___________________, Employer ___________________, Insurer Claimant’s Affidavit I, the undersigned claimant, state that I understand: 1. That I do not have to settle this case. If I settle this case, I waive certain rights. 2. If I do not settle this case, I understand: a. That I would have the right to have the issues in dispute in this case heard and decided by the Commission; b. That, as a result of the hearing, I might receive an award that is greater or less than the amount of this settlement. It is also possible that I would receive no additional benefits. c. That if I were dissatisfied with the Commission's decision, I would have the right to appeal. The employer and insurer also would have the right to appeal any decision by the Commission. d. That regardless of the Commission's hearing decision, I would have the right to file an application within the statutory time period to seek additional benefits if an initial award was entered. Once an award had been received, I would remain eligible at the employer/carrier's expense to receive all reasonable and necessary medical treatment related to the compensable injury/occupational disease for life. e. That I am aware that the Workers' Compensation Act would provide for the possibility of a total of 500 weeks compensation if I were disabled as a result of this work related accident or occupational disease, and the possibility of lifetime compensation if I were permanently and totally disabled as defined by the Act. 3. That I understand if I settle this case, and the settlement is approved, then I waive all of the rights set forth above. Further, I cannot obtain any additional compensation or medical benefits from the employer and insurer, other than those agreed to in the settlement. In addition, the Workers' Compensation Commission will be unable to provide any additional assistance. 4. That I am satisfied with the services of my attorney and aware that a fee for legal services will be approved by the Commission and deducted before payment of the net settlement proceeds to me. 5. THAT I FULLY UNDERSTAND THAT THIS SETTLEMENT FOREVER CLOSES MY CASE, INCLUDING ANY AND ALL COMPENSATION OR MEDICAL BENEFITS EXCEPT THOSE SPECIFICALLY LISTED IN THE SETTLEMENT. 6. That I have read or had the above information read and explained to me in my native language and fully understand all of the information in this affidavit and I request the Commission to approve this final compromise settlement. ________________________, Claimant STATE OF _____________________ CITY/COUNTY OF _______________ I, _________________, a Notary Public in and for the jurisdiction aforesaid, do hereby certify that ____________________, whose name is signed to the foregoing instrument, has acknowledged the same before me this _____ day of ___________, 200_. ___________________________, Notary Public Print Name: _____________________________ Notary Registration No.: ___________________ My Commission Expires _____________________ [Notary Seal] American LegalNet, Inc. www.FormsWorkflow.com