Form Wc-3pr-1 - Release And Settlement Of Claim Computation - 1981 Page 2
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1
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RELEASE AND SETTLEMENT OF CLAIM
For the Sole Consideration of _____________________________________Dollars ($
),
lawful money of the United States to me in hand paid by _________________________________
___________________the receipt of which is hereby acknowledged, I _____________________
________________residing at _____________________________________________________
do hereby release, acquit, and forever discharge the said ________________________________
______________________________________________________________________________
from any and all actions, causes of action, claims and demands, damages, costs, loss of services,
expenses, and compensation on account of or in any way growing out of any and all known and
unknown personal injuries and property damage resulting or to result from the accident that
occurred
on
or
about
the
____________
day
of
_____________,
by
reason
of
______________________________________________________________________________
______________________________________________________________________________
and do hereby for myself, my heirs, executor, and administrator, successors and assigns covenant
with the said ___________________________________________________________________
______________________________________________________________________________
to indemnify and save harmless from all claims and demands, costs, loss of services, expenses,
and compensation on account of or in any way growing out of said accident or its result both to
person and property, provided however that there shall be deducted from the above sum, pursuant
to RSA 281-A:13, an amount of money equivalent to compensation and the costs of medical,
hospital or other remedial care already paid or agreed or awarded to be paid by the employer or
employer’s Insurance carrier _______________________________________________________
______________________________________________________________________________
under RSA 281-A:13, as amended, said amount being that in Line 4 of Page 2 of this document,
__________________________________ Dollars ($
), less the employer’s or the
employer’s insurance carrier’s, pro rata share of expenses and costs of action, if any, as
determined under RSA 281-A:13, IV, and provided further that such net amount, being that in Line
6 of said Page 2, ________________________________________________________________
____________ Dollars ($
), be paid to the employer or the carrier in satisfaction
of one or the other’s lien. It is expressly understood and agreed that the acceptance of the said
amount of ___________________________ Dollars ($
), is in full accord and satisfaction
of my claim in this matter.
In Witness Whereof, I have set my hand and seal this _________day of _____________,_______
_______________________________________ Name______________________________ (LS)
(Witness)
_______________________________________ Address ________________________________
(Address)
On this ____________ day of _____________, _______, before me personally appeared
______________________________________________________________________________
to be known to be the person described herein, and who executed the foregoing instrument, and
he/she acknowledged that he/she voluntarily executed the same.
___________________________________
Notary Public
Approval of the Commissioner of Labor granted on this _________day of ____________, ______
Pursuant to par. III, RSA 281-A:13.
___________________________________
Commissioner of Labor
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