Free LIBC-755 REV 4-04.pmd - Pennsylvania

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 TTY 800-362-4228 www.dli.state.pa.us

COMPROMISE AND RELEASE AGREEMENT BY STIPULATION PURSUANT TO SECTION 449 OF THE WORKERS' COMPENSATION ACT Employer

Date of Injury: _______ /_______/________
MM DD YYYY

PA BWC Claim Number: __________________
(IF KNOWN)

Employee
First Name __________________________________ Street 1 ________________________________________________________________________________________ Street 2 _______________________________________________________________________________________ City/Town _______________________________________________ County _______________________________________________ State ________ Zip Code ________ - _______________ Last Name

Name ______________________________________________________________________________________ Street 1 ________________________________________________________________________________________ Street 2 _______________________________________________________________________________________ City/Town _______________________________________________ County _______________________________________________ Telephone (_________) ________ - _______________ FEIN __________________________________ State ________ Zip Code ________ - _______________

Telephone (_________) ________ - ______________

TO THE PARTIES: DO NOT SUBMIT THIS AGREEMENT TO THE BUREAU. SUBMIT IT TO THE ASSIGNED WORKERS' COMPENSATION JUDGE. TO THE EXTENT THIS AGREEMENT REFERENCES AN INJURY FOR WHICH LIABILITY HAS NOT BEEN RECOGNIZED BY AGREEMENT OR BY ADJUDICATION, THE TERM "INJURY" AS USED IN THIS AGREEMENT SHALL MEAN "ALLEGED INJURY".

Insurer or Third Party Administrator (if self-insured)
Name ______________________________________________________________________________________ Street 1 ________________________________________________________________________________________ Street 2 _______________________________________________________________________________________ City/Town _______________________________________________ County _______________________________________________ Telephone (_________) ________ - _______________ Insurer/TPA Claim Number Bureau Code __________________________________ FEIN State ________ Zip Code ________ - _______________

1. This is an agreement in the case of the above listed employee and the above listed employer, insurer, or third party administrator in regards to an injury or occupational disease. 2. State the date of injury or occupational disease ______/ ______/ _________ .
MM DD YYYY

3. State the average weekly wage of the employee, as calculated under Section 309. $ _____________ . _____/wk 4. State the injury, the precise nature of the injury, and the nature of the disability, whether total or partial.

5. State the weekly compensation rate paid or payable. $ _____________ . _____/wk 6. State the amount of indemnity benefits paid or due and unpaid to the employee or dependent up to the date of the stipulation or agreement or death. $ _____________ . _____ 7. State the amount of the payment of indemnity benefits to be made at or after the date of the stipulation or agreement or death, and the length of time such payment of benefits is to continue. $ _____________ . _____ for _______________________________
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8. Does this claim arise out of the death of an employee? If Yes, provide the following information: a. Date of death: ______/ ______/ _________
MM DD YYYY

Yes

No

b. Name and address of the widow or widower (include any maiden names, aliases and name upon remarriage, if applicable):

c.

Names, addresses and dates of birth of all children:

d. If it is claimed that the dependency of any child continues beyond the age of eighteen (18) years, identify that child and state specifically the factual basis for this claim.

e. State the name, address and relationship to the employee of any other person claiming to be a dependent, together with a brief summary of the factual basis for this claim.

9. Summarize all of the medical benefits paid, or due and unpaid, to or on behalf of the employee (or each dependent identified in Paragraph 8 above) up to the date of this agreement.

10. Summarize all benefits to be paid on and after the date of this stipulation or agreement for reasonable and necessary medical treatment causally related to the injury and the length of time such payment of benefits is to continue.

11. Is there an actual or potential lien for subrogation under Section 319? Yes No If Yes, state the name and address (if known) of the entity asserting the lien and the total amount of compensation, including medicals, paid or payable, which should be allowed to that entity.

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12. Are there any current child or spousal support orders in place against the claimant? If Yes, please explain:

Yes

No

13. List all benefits received by, or available to, the claimant; e.g. Social Security (Disability or Retirement) private health insurance, Medicare, Medicaid, etc. For such benefits, list the amount(s), period of payments of benefits, and status of eligibility determination.

14. Check as appropriate: A vocational evaluation of the employee was completed on ______/_____/_______ by ___________________. MM DD YYYY A copy of this report is attached hereto.

- OR A vocational evaluation of the employee has been waived by mutual agreement of the parties. 15. State the issues involved in this claim and the reasons why the parties are entering into this agreement.

16. The fee agreement between claimant and counsel must be attached. 17. Employer shall be responsible for litigation costs in the total amount of $ _____________ . _____ . 18. Miscellaneous provisions, if any.

REMINDER TO PARTIES: Upon approval of this Agreement, please promptly withdraw all appeals pending before the Workers' Compensation Appeal Board, Commonwealth Court, Pennsylvania Supreme Court, etc., which are also resolved by this Agreement.
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EMPLOYEE'S CERTIFICATION
1. I certify that I have read this entire agreement, or to the best of my knowledge, information and belief (if applicable) this agreement has been read to me, and I understand all of the contents of this agreement as well as the full legal significance and consequences of entering into this agreement. 2. I understand that, if this agreement is approved, I will receive only the benefits mentioned in this agreement, unless the agreement provides specifically for additional amounts. I understand that my employer, its insurance company or its administrator will never have to pay any other workers' compensation benefits for the injury. 3. Except for the amounts or benefits listed in this agreement, I have been offered nothing of value to convince me to sign this agreement. 4. I have been represented by an attorney of my own choosing during this case. My attorney has explained to me the content of this agreement and its effects upon my rights. __________ (Employee's Initials)

- OR I have not been represented by an attorney of my own choosing. However, I have been told that I have the right to be represented by an attorney of my own choosing in this proceeding. I have made my own decision not to have an attorney represent me. __________ (Employee's Initials) 5. Unless specifically stated in this agreement, I understand that this agreement is a compromise and release of a workers' compensation claim, and is not considered an admission of liability by employer and/or insurer and/or administrator.

DO NOT SIGN THIS DOCUMENT UNLESS YOU UNDERSTAND THE FULL LEGAL SIGNIFICANCE OF THIS AGREEMENT.
All parties have read this agreement and agree to its contents. We understand that under this agreement, all petitions are resolved. Dated: ______ / ______ / ________ ____________________________________________
MM DD YYYY EMPLOYEE (SIGNATURE)

_______________________________________________
WITNESS TO EMPLOYEE'S SIGNATURE

____________________________________________
EMPLOYEES COUNSEL

_______________________________________________
WITNESS TO EMPLOYEE'S SIGNATURE

____________________________________________
EMPLOYER/INSURER/THIRD PARTY ADMINISTRATOR (SIGNATURE)

____________________________________________
EMPLOYER/INSURER/THIRD PARTY ADMINISTRATOR COUNSEL

If not witnessed above, this agreement must be notarized as follows: AFFIDAVIT/ACKNOWLEDGMENT: Before me, the undersigned Notary Public, in and for the aforesaid County and State, personally appeared __________________________________________ who being first duly sworn, does depose and state that he/she knows (or has satisfactorily proven to be) the individual identified as the employee in the foregoing compromise and release agreement; and that he/she has executed the foregoing compromise and release agreement for the purposes stated herein. _______________________________________
NOTARY PUBLIC

THE COMPROMISE AND RELEASE AGREEMENT IS NOT VALID AND BINDING UNLESS APPROVED BY A WORKERS' COMPENSATION JUDGE IN A DECISION. Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program
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