Dwc-Ca Form 10214 - State Of California Division Of Workers' Compensation Workers' Compensation Appeals Board Third Party Compromise And Release - 2008 Page 4

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5. Medical and hospital expenses have been paid $
by the employee and $
by employer or carrier. Unpaid bills amount to $
Future medical and hospital expense
.
is estimated at $
Unpaid and future medical and hospital expense is to be assumed as follows:
.
6. Name and address of employee's attorney, if any
Law Firm or Company Name (If Applicable)
Attorney/Rep First Name
MI
Attorney/Rep Last Name
Address/PO Box (Please leave blank spaces between numbers, names or words)
Suite/Apt#
State
City
Zip Code
7. It is claimed that the injury to the employee was caused by the negligence of
An agreement has been reached for settlement in full of the employee's claim for personal injury against said alleged tort-feasor
for the sum of $
.
Yes
No
8. Copy of settlement agreement between employee and the alleged tort-feasor is attached.
(Copy must be attached if in writing, or explanation given)
9. From said sum the employee's attorney requests a fee of $
and $
for expenses incurred [Note attach supporting statements, e.g. Court agreement, services rendered, etc. See Labor Code
section 3860(f)] leaving a balance of $
to be divided between the employee and the
. To Employee $
.
(Carrier or Self insured)
Court approval
documents
To:
attached
(Carrier or Self insured)
to carrier or self insured employer
$
.
10. Reason for compromise (include issues that would be raised in event of proceedings under provisions of paragraph 13)
DWC-CA form 10214 (e) (PAGE 4) (REV. 11/2008)

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