Name (Bar #) _________________________
Law Firm ____________________________
Address ______________________________
Phone # ______________________________
Fax # ________________________________
Attorney for_________________________
INJURED WORKER, Petitioner,
COMPROMISE AGREEMENT
______________________________
v s .
Case No. _____________
EMPLOYER; CARRIER, Respondents.
DUTY JUDGE _____________
______________________________
1. Industrial Accident/Occupational Disease Claim
a. On ____________ , 20___, or in the time period of __________________________ ,
___________________Injured Worker asserts he/she sustained an industrial
accident / occupational disease while employed with ___________________ (“Employer”).
_______________________ (“Carrier”) provided the employer with workers’ compensation
coverage on that date/time period.
b. Injured Worker asserts the industrial accident/occupational exposure occurred as follows:
___________________________________________________________________________________
___________________________________________________________________________________
c. As a result of the alleged accident/occupational exposure, the Injured Worker claims to
have sustained the following industrial injuries:
_____________________________________________________________________________
d. Respondents assert that a legitimate defense or dispute exists to Injured Worker’s claims,
based on:
Examples:
the Injured Worker did not sustain an industrial accident/occupational disease within the
course and scope of his/her employment because ___________________________ .
the Injured Worker cannot prove medical causation, or cannot prove the
medical treatment requested in medically necessary, based on the opinion of
Dr. _________________ . A copy of Dr. _____________________ ’s report is attached.
Dr._________________ opines that the Injured Worker had preexisting conditions
which contributed to the industrial injuries and the Injured Worker cannot prove the
higher standard of legal causation. Dr. ______________ ’s report is attached.