Fillable Dwc-Ca Form 10214 - Compromise And Release

Specific Injury

Cumulative Injury

Case Number 5

(Start Date: MM/DD/YYYY)

(End Date: MM/DD/YYYY)

(If Specific Injury, use the start date as the specific date of injury)

Body Part 1:

Body Part 2:

Body Part 3:

Body Part 4:

Other Body Parts:

The injury occurred at

(Street Address/PO Box - Please leave blank spaces between numbers, names or words)

City

State

Zip Code

Body parts, conditions and systems may not be incorporated by reference to medical reports.

2. Upon approval of this compromise agreement by the Workers' Compensation Appeals Board or a workers' compensation

administrative law judge and payment in accordance with the provisions hereof, the employee releases and forever

discharges the above-named employer(s) and insurance carrier(s) from all claims and causes of action, whether now known

or ascertained or which may hereafter arise or develop as a result of the above-referenced injury(ies), including any and all

liability of the employer(s) and the insurance carrier(s) and each of them to the dependents, heirs, executors,

representatives, administrators or assigns of the employee. Execution of this form has no effect on claims that are not within

the scope of the workers' compensation law or claims that are not subject to the exclusivity provisions of the workers'

compensation law, unless otherwise expressly stated.

3. This agreement is limited to settlement of the body parts, conditions, or systems and for the dates of injury set forth in

Paragraph No. 1 and further explained in Paragraph No. 9 despite any language to the contrary elsewhere in this document or

any addendum.

4. Unless otherwise expressly stated, approval of this agreement RELEASES ANY AND ALL CLAIMS OF APPLICANT'S

DEPENDENTS TO DEATH BENEFITS RELATING TO THE INJURY OR INJURIES COVERED BY THIS COMPROMISE

AGREEMENT. The parties have considered the release of these benefits in arriving at the sum in Paragraph 7. Any addendum

duplicating this language pursuant to Sumner v WCAB (1983) 48 CCC 369 is unnecessary and shall not be attached.

5. Unless otherwise expressly ordered by the Workers' Compensation Appeals Board or a workers' compensation

administrative law judge, approval of this agreement does not release any claim applicant may have for vocational

rehabilitation benefits or supplemental job displacement benefits.

6. The parties represent that the following facts are true: (If facts are disputed, state what each party contends under

Paragraph No. 9.)

EARNINGS AT TIME OF INJURY $

TEMPORARY DISABILITY INDEMNITY PAID

Weekly Rate $

Period(s) Paid

(Start Date: MM/DD/YYYY)

(End Date: MM/DD/YYYY)

PERMANENT DISABILITY INDEMNITY PAID

Weekly Rate $

Period(s) Paid

End date

(Start Date: MM/DD/YYYY)

(End Date: MM/DD/YYYY)

Total Unpaid Medical Expense to be Paid By:

TOTAL MEDICAL BILLS PAID $

Unless otherwise specified herein, the employer will pay no medical expenses incurred after approval of this agreement.

DWC-CA form 10214 (c) (Rev. 11/2008) (Page 5 of 9)

Dwc-Ca Form 10214 - Compromise And Release - 2008 Page 5

Related Articles

Related forms

Related Categories