Compromise Agreement - Utah

This Utah-specific printable "Compromise Agreement" is a part of the legal paperwork issued by the Utah Labor Commission.

Download the up-to-date PDF by clicking the link below and mail it as per the guidelines provided by the department.

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Name (Bar #) _________________________
Law Firm ____________________________
Address ______________________________
Phone # ______________________________
Fax # ________________________________
Attorney for_________________________
INJURED WORKER, Petitioner,
COMPROMISE AGREEMENT
______________________________
v s .
Case No. _____________
EMPLOYER; CARRIER, Respondents.
DUTY JUDGE _____________
______________________________
1. Industrial Accident/Occupational Disease Claim
a. On ____________ , 20___, or in the time period of __________________________ ,
___________________Injured Worker asserts he/she sustained an industrial
accident / occupational disease while employed with ___________________ (“Employer”).
_______________________ (“Carrier”) provided the employer with workers’ compensation
coverage on that date/time period.
b. Injured Worker asserts the industrial accident/occupational exposure occurred as follows:
___________________________________________________________________________________
___________________________________________________________________________________
c. As a result of the alleged accident/occupational exposure, the Injured Worker claims to
have sustained the following industrial injuries:
_____________________________________________________________________________
d. Respondents assert that a legitimate defense or dispute exists to Injured Worker’s claims,
based on:
Examples:
the Injured Worker did not sustain an industrial accident/occupational disease within the
course and scope of his/her employment because ___________________________ .
the Injured Worker cannot prove medical causation, or cannot prove the
medical treatment requested in medically necessary, based on the opinion of
Dr. _________________ . A copy of Dr. _____________________ ’s report is attached.
Dr._________________ opines that the Injured Worker had preexisting conditions
which contributed to the industrial injuries and the Injured Worker cannot prove the
higher standard of legal causation. Dr. ______________ ’s report is attached.
Name (Bar #) _________________________
Law Firm ____________________________
Address ______________________________
Phone # ______________________________
Fax # ________________________________
Attorney for_________________________
INJURED WORKER, Petitioner,
COMPROMISE AGREEMENT
______________________________
v s .
Case No. _____________
EMPLOYER; CARRIER, Respondents.
DUTY JUDGE _____________
______________________________
1. Industrial Accident/Occupational Disease Claim
a. On ____________ , 20___, or in the time period of __________________________ ,
___________________Injured Worker asserts he/she sustained an industrial
accident / occupational disease while employed with ___________________ (“Employer”).
_______________________ (“Carrier”) provided the employer with workers’ compensation
coverage on that date/time period.
b. Injured Worker asserts the industrial accident/occupational exposure occurred as follows:
___________________________________________________________________________________
___________________________________________________________________________________
c. As a result of the alleged accident/occupational exposure, the Injured Worker claims to
have sustained the following industrial injuries:
_____________________________________________________________________________
d. Respondents assert that a legitimate defense or dispute exists to Injured Worker’s claims,
based on:
Examples:
the Injured Worker did not sustain an industrial accident/occupational disease within the
course and scope of his/her employment because ___________________________ .
the Injured Worker cannot prove medical causation, or cannot prove the
medical treatment requested in medically necessary, based on the opinion of
Dr. _________________ . A copy of Dr. _____________________ ’s report is attached.
Dr._________________ opines that the Injured Worker had preexisting conditions
which contributed to the industrial injuries and the Injured Worker cannot prove the
higher standard of legal causation. Dr. ______________ ’s report is attached.
Injured Worker
Compromise Agreement
The Injured Worker cannot prove ___________________________ , as supported by
___________________________ , which justifies settling this case on a disputed basis.
2. Injured Worker did/did not previously file an Application for Hearing with the Utah Labor
Commission’s Adjudication Division in this matter. That Application for Hearing was assigned the
case number(s) ____________ . The outcome of that case was: _______________________ .
3. Compensation
a. At the time of the industrial accident/occupational exposure, Employer employed Injured Worker
as a ___________________. Injured Worker earned $ ______ per ______ and worked ____
hours per week. As a result, Injured Worker’s weekly average wage totaled ___________ .
Injured Worker was/was not married and had _____ dependants at the time of the industrial
accident/occupational exposure. Injured Worker’s weekly temporary total compensation rate
totals ____________; Injured Worker’s weekly permanent partial disability compensation rate
totals _____________; and Injured Worker’s weekly permanent total disability compensation
rate totals
.
4. Industrial Injury/Occupational Disease Medical Treatment Subsequent to the
Industrial Accident/Occupational Exposure
a. Injured Worker has received the following medical treatment as a result of Injured
Worker’s alleged industrial accident/occupational exposure (summarize):
.
b. Injured Worker’s most recent treatment was with Dr. __________ on_________________ .
c. The Injured Worker’s current condition is as follows: (describe frequency of medical
treatment and medications, etc.)
d. The Injured Worker’s date of birth is ________________ .
e. The Injured Worker became stable on _____________ as opined by Dr. ____________________.
f. The Injured Worker has the following permanent restrictions:
__________________________________________________________________________________
g. Dr(s). ____________has opined the following in regard to the Injured Worker’s ability to return
to work:
___________________________________________________________________________________________
___________________________________________________________________________________________
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Injured Worker
Compromise Agreement
5.
As a result of subject industrial accident/occupational disease, Respondents have already paid
Injured Worker the following in workers’ compensation benefits. (Payment of these benefits does
not constitute an admission that Injured Worker’s accident/disease is compensable.):
_____________________________________________________________________________________
FINAL SETTLEMENT AND RELEASE AGREEMENT
Based on the foregoing, and after considering their respective legal and medical positions, the parties
in this case desire to buy their peace without further litigation, and enter into this permanent,
binding, full and final settlement. The parties consider it to be in their best interest to enter into a
permanent, binding, full and final settlement of this matter and agree on the following terms:
1. In consideration of Respondents’ lump sum payment in the amount of $ _____________ , and
with respect to all alleged injuries arising out of the alleged industrial accident/occupational
disease, the Injured Worker, _____________________ , unconditionally releases, acquits, and
forever discharges Injured Worker’s employer, _______________ , and its workers
compensation carrier, ____________________ , from all existing and future claims for
workers’ compensation benefits, including temporary total disability compensation,
temporary partial disability compensation, permanent partial disability compensation,
permanent total disability compensation, medical expenses, travel expenses, and interest
arising out of or resulting from the alleged (date) industrial accident/occupational disease.
2. In consideration and exchange for the foregoing release, Respondents ______________ and
______________________ agree to pay the lump sum of $ _____________ (spell out numbers)
directly to Injured Worker___________________ . Of this sum, $ _______________ will be
deducted and paid directly to________________ ______ for attorney’s fees.
3. Each party understands that this Final Settlement and Release Agreement is permanent, binding,
and constitutes a full and final settlement of any right the Injured Worker, ______________ ,
may otherwise have to benefits from Respondents _________________and
_________________. This settlement is contractual in nature and not a mere recital, and is
intended as a final and binding settlement not subject to further modification.
DISCLOSURES
1.
The parties certify that they have read the INFORMATION FOR INJURED
WORKERS REGARDING SETTLEMENT AGREEMENTS sheet.
2.
The parties represent that no costs for treatment or compensation will be shifted to third parties
(including private insurance carrier, governmental agency, etc.) as a result of this agreement.
3.
The parties knowingly give up any right to an administrative hearing at the Utah Labor
Commission, in which the administrative law judge could award the Injured Worker more
money, less money, or no money.
Page 3 of 4
Injured Worker
Compromise Agreement
4. Injured Worker understands that if his/her current medical condition becomes more serious in
the future, or if he/she develops new medical problems that he/she attributes to this accident in
the future, or becomes unable to work as a result of the industrial injuries, he/she cannot come
back to Respondents or the Utah Labor Commission and ask for more money or benefits.
5. Injured Worker has consulted an attorney of his/her choice regarding this settlement, or has had
the choice to consult with an attorney but declines to do so.
6. Injured Worker acknowledges that his/her decision to settle this claim is his/her sole independent
and fully informed decision. Injured Worker has carefully read this Disputed Settlement
Agreement, knows the contents thereof, and signs this as his/her own free act. Injured Worker has
discussed the Settlement Agreement and its contents fully with his/her attorney.
7. The parties acknowledge that this Settlement Agreement contains the entire agreement between the
parties and that the terms of this Settlement Agreement are contractual and not a mere recital.
8. This Settlement Agreement shall become binding and effective only when approved by the Utah
Labor Commission. Upon such approval, Injured Worker’s workers’ compensation claims
against Respondents related to Injured Worker’s (date) industrial accident/occupational disease
are dismissed with prejudice.
Dated this ___ day of _______________, 20____.
(Name)
Injured Worker
Dated this ___ day of _______________, 20____.
(Name)
Attorney for Injured Worker
Dated this ___ day of ________________, 20____.
___________________________________
(Name)
Attorney for Respondents
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