Affidavit In Support Of Redemption Settlement Agreement
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AFFIDAVIT IN SUPPORT OF REDEMPTION (SETTLEMENT) AGREEMENT
Michigan Department of Licensing and Regulatory Affairs
Workers’ Compensation Agency/Board of Magistrates
PO Box 30016, Lansing, MI 48909
________________________________________
Plaintiff
______________________
County
____________________________________
Defendant
I, _______________________________________________________, the plaintiff in this case against
____________________________________________________________, the defendant(s),
affirm that the following are true and correct statements:
1.
While employed by ________________________________________________, the defendant(s),
I was injured on or about ________________________________. (Date)
2.
I have been offered the sum of $ ___________________________________ to settle my workers’
compensation claim, both weekly and medical benefits and possible rehabilitation.
3.
I understand that by accepting this amount of money I am waiving all workers’ compensation rights
I may have against this (these) defendant(s) and its (their) workers’ compensation insurance
carrier(s).
4.
I have voluntarily entered into the redemption agreement.
5.
If I have filed an Application for Mediation or Hearing under the Michigan Workers’ Disability
Compensation Act, the application alleges a compensable condition.
6.
My attorney, or the magistrate, has fully explained to me the rights that I have under the Workers’
Disability Compensation Act and I understand that this redemption agreement, if approved by the
magistrate, will extinguish all of those rights.
7.
I have fully disclosed to my attorney, or the magistrate, any other benefits that I am receiving or
may be entitled to receive and it has been explained to me what effect, if any, the redemption
agreement might have on those other benefits. Those other benefits are
8.
I have fully disclosed to my attorney, or the magistrate, the nature and extent of the injuries and/or
disabilities incurred by me during my employment with the defendant(s). Those injuries are:
(Over)
WC-119 (412) Front
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