Worker'S Compromise Agreement Form Page 2
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4Injured Worker
Compromise Agreement
The Injured Worker cannot prove ___________________________ , as supported by
___________________________ , which justifies settling this case on a disputed basis.
2. Injured Worker did/did not previously file an Application for Hearing with the Utah Labor
Commission’s Adjudication Division in this matter. That Application for Hearing was assigned the
case number(s) ____________ . The outcome of that case was: _______________________ .
3. Compensation
a. At the time of the industrial accident/occupational exposure, Employer employed Injured Worker
as a ___________________. Injured Worker earned $ ______ per ______ and worked ____
hours per week. As a result, Injured Worker’s weekly average wage totaled ___________ .
Injured Worker was/was not married and had _____ dependants at the time of the industrial
accident/occupational exposure. Injured Worker’s weekly temporary total compensation rate
totals ____________; Injured Worker’s weekly permanent partial disability compensation rate
totals _____________; and Injured Worker’s weekly permanent total disability compensation
rate totals
.
4. Industrial Injury/Occupational Disease Medical Treatment Subsequent to the
Industrial Accident/Occupational Exposure
a. Injured Worker has received the following medical treatment as a result of Injured
Worker’s alleged industrial accident/occupational exposure (summarize):
.
b. Injured Worker’s most recent treatment was with Dr. __________ on_________________ .
c. The Injured Worker’s current condition is as follows: (describe frequency of medical
treatment and medications, etc.)
d. The Injured Worker’s date of birth is ________________ .
e. The Injured Worker became stable on _____________ as opined by Dr. ____________________.
f. The Injured Worker has the following permanent restrictions:
__________________________________________________________________________________
g. Dr(s). ____________has opined the following in regard to the Injured Worker’s ability to return
to work:
___________________________________________________________________________________________
___________________________________________________________________________________________
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