Worker'S Compromise Agreement Form Page 3
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4Injured Worker
Compromise Agreement
5.
As a result of subject industrial accident/occupational disease, Respondents have already paid
Injured Worker the following in workers’ compensation benefits. (Payment of these benefits does
not constitute an admission that Injured Worker’s accident/disease is compensable.):
_____________________________________________________________________________________
FINAL SETTLEMENT AND RELEASE AGREEMENT
Based on the foregoing, and after considering their respective legal and medical positions, the parties
in this case desire to buy their peace without further litigation, and enter into this permanent,
binding, full and final settlement. The parties consider it to be in their best interest to enter into a
permanent, binding, full and final settlement of this matter and agree on the following terms:
1. In consideration of Respondents’ lump sum payment in the amount of $ _____________ , and
with respect to all alleged injuries arising out of the alleged industrial accident/occupational
disease, the Injured Worker, _____________________ , unconditionally releases, acquits, and
forever discharges Injured Worker’s employer, _______________ , and its workers
compensation carrier, ____________________ , from all existing and future claims for
workers’ compensation benefits, including temporary total disability compensation,
temporary partial disability compensation, permanent partial disability compensation,
permanent total disability compensation, medical expenses, travel expenses, and interest
arising out of or resulting from the alleged (date) industrial accident/occupational disease.
2. In consideration and exchange for the foregoing release, Respondents ______________ and
______________________ agree to pay the lump sum of $ _____________ (spell out numbers)
directly to Injured Worker___________________ . Of this sum, $ _______________ will be
deducted and paid directly to________________ ______ for attorney’s fees.
3. Each party understands that this Final Settlement and Release Agreement is permanent, binding,
and constitutes a full and final settlement of any right the Injured Worker, ______________ ,
may otherwise have to benefits from Respondents _________________and
_________________. This settlement is contractual in nature and not a mere recital, and is
intended as a final and binding settlement not subject to further modification.
DISCLOSURES
1.
The parties certify that they have read the INFORMATION FOR INJURED
WORKERS REGARDING SETTLEMENT AGREEMENTS sheet.
2.
The parties represent that no costs for treatment or compensation will be shifted to third parties
(including private insurance carrier, governmental agency, etc.) as a result of this agreement.
3.
The parties knowingly give up any right to an administrative hearing at the Utah Labor
Commission, in which the administrative law judge could award the Injured Worker more
money, less money, or no money.
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