Free Claimant's Affidavit in Support of Settlement H-05 - Maryland

Workers' Compensation Commission

CLAIMANT'S AFFIDAVIT IN SUPPORT OF SETTLEMENT
I, , am the claimant in claim # . I ask the Workers' Compensation Commission to approve the settlement of my claim and in support of this request state: 1. that I am voluntarily settling my claim; 2. that in so doing I am giving up the following rights: a. the right to hearings before the Workers' Compensation Commission for resolution of any disputes regarding my claim; b. the right to vocational rehabilitation services and to payment during my lifetime for any medical treatment related to my claim, except as provided, if at all, in this settlement; c. the right, except as provided, if at all, in this settlement, to be compensated, under certain conditions, by the Subsequent Injury Fund for permanent impairments incurred before the accidental injury or occupational disease which gave rise to my claim; d. the right to ask the Workers' Compensation Commission, within 5 years of the last payment of any compensation that it might have ordered, to reopen my claim should my condition related to my claim worsen; e. the right to appeal to the appropriate Circuit Court if I were dissatisfied with a decision of the Workers' Compensation Commission; f. the right to appeal to the Court of Special Appeals if I were dissatisfied with the decision of the Circuit Court; and g. the right to petition the Court of Appeals to review the decision of the Court of Special Appeals if I were dissatisfied with the decision of the Court of Special Appeals; and 3. that, by signing this affidavit, I acknowledge that I have read, and understand, the terms of this settlement and all the documents attached in support of it, including medical reports and this affidavit. I, as attorney for the claimant, have reviewed this Affidavit with the claimant.

___________________________________ Claimant's Signature

Claimant's Name (printed)

Attorney for Claimant

Date

Date
10 East Baltimore Street q Baltimore, Maryland 21202-1641 410-864-5100 q Email: [email protected] qWeb: http://www.wcc.state.md.us

WCC H-05 (Rev. 9/05/03)

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