Fillable Dwc-Ca Form 10214 - Compromise And Release

Dwc-Ca Form 10214 - Compromise And Release - 2008 Page 8

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11. WARNING TO EMPLOYEE: SETTLEMENT OF YOUR WORKERS' COMPENSATION CLAIM BY COMPROMISE AND

RELEASE MAY AFFECT OTHER BENEFITS YOU ARE RECEIVING TO WHICH YOU BECOME ENTITLED TO RECEIVE IN

THE FUTURE FROM SOURCES OTHER THAN WORKERS' COMPENSATION, INCLUDING BUT NOT LIMITED TO

SOCIAL SECURITY, MEDICARE AND LONG-TERM DISABILITY BENEFITS.

THE APPLICANT'S (EMPLOYEE'S) SIGNATURE MUST BE ATTESTED TO BY TWO DISINTERESTED PERSONS

OR ACKNOWLEDGED BEFORE A NOTARY PUBLIC

By signing this agreement, applicant (employee) acknowledges that he/she has read and understands this agreement and

has had any questions he/she may have had about this agreement answered to his/her satisfaction.

Witness the signature hereof this ________ day of ______________, ________________ at

(Date)

Witness 1

Applicant (Employee)

(Date)

Witness 2

Attorney for Applicant

(Date)

Interpreter

Attorney for Defendant

(Date)

Attorney for Defendant

(Date)

Attorney for Defendant

(Date)

Attorney for Defendant

(Date)

DWC-CA form 10214 (c) (Rev.11/2008) (Page 8 of 9)

Dwc-Ca Form 10214 - Compromise And Release - 2008 Page 8

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