Worker'S Compromise Agreement Form Page 4
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4Injured Worker
Compromise Agreement
4. Injured Worker understands that if his/her current medical condition becomes more serious in
the future, or if he/she develops new medical problems that he/she attributes to this accident in
the future, or becomes unable to work as a result of the industrial injuries, he/she cannot come
back to Respondents or the Utah Labor Commission and ask for more money or benefits.
5. Injured Worker has consulted an attorney of his/her choice regarding this settlement, or has had
the choice to consult with an attorney but declines to do so.
6. Injured Worker acknowledges that his/her decision to settle this claim is his/her sole independent
and fully informed decision. Injured Worker has carefully read this Disputed Settlement
Agreement, knows the contents thereof, and signs this as his/her own free act. Injured Worker has
discussed the Settlement Agreement and its contents fully with his/her attorney.
7. The parties acknowledge that this Settlement Agreement contains the entire agreement between the
parties and that the terms of this Settlement Agreement are contractual and not a mere recital.
8. This Settlement Agreement shall become binding and effective only when approved by the Utah
Labor Commission. Upon such approval, Injured Worker’s workers’ compensation claims
against Respondents related to Injured Worker’s (date) industrial accident/occupational disease
are dismissed with prejudice.
Dated this ___ day of _______________, 20____.
(Name)
Injured Worker
Dated this ___ day of _______________, 20____.
(Name)
Attorney for Injured Worker
Dated this ___ day of ________________, 20____.
___________________________________
(Name)
Attorney for Respondents
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