Mediated Settlement Agreement (Page 2 of 3) in pdf

Mediated Settlement Agreement Page 2

7. Other:

8. The parties and their respective attorneys acknowledge all material terms are included in this agreement; it is fair

and in the best interests of all parties and consent to the Industrial Commission reviewing this Agreement and

entering an Order approving this settlement agreement based on the terms and conditions contained herein.

9. This Agreement contains all the provisions required for enforceability of a Compromise Settlement Agreement,

as set out in Rule 502, et al., specifically Rule 502 (2) (a), (b), (c), (d), (e), (f), (g), and (h). By signing this Mediated

Settlement Agreement, plaintiff verifies he/she knowingly and intentionally waives his/her right to further benefits

under the Workers’ Compensation Act for the injury/occupational disease which is the subject of this agreement.

10. Entered into this the _____ day of __________________, _____.

By signing below, the mediator attests the parties signed this

agreement in his/her presence at the conclusion of mediation.

____________________________

Plaintiff

Defendant

Mediator

____________________________

Plaintiff’s Attorney

Defendant’s Attorney

Mediated Settlement Agreement Page 2