Dwc-Ca Form 10214 - Compromise And Release - 2008 Page 6
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97. The parties agree to settle the above claim(s) on account of the injury(ies) by the payment of the SUM OF
$
Settlement Amount
The following amounts are to be deducted from the settlement amount:
$
for permanent disability advances through
$
for temporary disability indemnity overpayment, if any.
$
payable to
$
payable to
$
payable to
$
payable to
$
requested as applicant's attorney's fee.
, after deducting the amounts set forth above and less
LEAVING A BALANCE OF $
further permanent disability advances made after the date set forth above. Interest under Labor Code section 5800 is
included if the sums set forth herein are paid within 30 days after the date of approval of this agreement.
8. Liens not mentioned in Paragraph No. 7 are to be disposed of as follows (Attach an addendum if necessary):
DWC-CA form 10214 (c) (Rev. 11/2008) (Page 6 of 9)
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