PERSONAL INJURY CLAIMS
Release executed on _______________________ (month
& day), _________ (year), by ___________________________ (name)
(address), here referred to as releasor, to
____________________________________ (name), a corporation incorporated under
the laws of the State of _________________, of (or, if a corporation: with its
principal place of business located at) ______________
here referred to as company.
has been employed by company as a ____________________________ (set forth job
title or description) since ______________________ (month & day), _________
(year), and __________ (earns the sum of ____________________ Dollars
($_________) per week or set forth average weekly wage as determined under
workers compensation law).
_____________________ (month & day), _________ (year), releasor sustained personal
injuries, including ________________________________________________
______________ (enumerate), as a result of an accident that occurred as
above-described personal injuries are ________________ (total or partial) and
have been determined to be _________________________ (permanent or temporary)
D. Prior to
the date of this release, ______________________ (month & day), ______
(year), the sum of __________________ Dollars ($__________) has been paid (or
is due and unpaid) to releasor as benefits under the _________________ (state)
workers compensation law or otherwise as the case may be). The sum of __________________ Dollars
($__________) in additional payments is to be made to releasor, such payments
continuing until ________________________ (month & day), ___________
(year), or for a period of ____________ weeks.
__________ (In the event of a claim or lien for unemployment benefits, the
number of days and the amount of temporary disability indemnity for which a
lien should be allowed should be set out.)
is willing to release company from all claims that ____________ (he/she) may
have in relation to the above-described personal injuries according to the
terms of this instrument.
OF ALL CLAIMS
In consideration of the sum of ____________ Dollars
($__________ ), receipt of which from company is hereby acknowledged, releasor
executes this release in full settlement of all claims as hereinafter set forth
for ______________________ (himself/herself), and ____________ (his/her)
dependents, heirs, legal representatives and assigns, releasor forever releases
and discharges company, its agents, officers, employees, successors and
assigns, of and from any and all claims, demands, actions and causes of action
or suits at law or in equity for and on account of any and all known and
unknown injuries, disabilities, physical and mental, diseases, damages, losses
and expenses sustained by _____________ (him/her) or anyone claiming under
____________ (him/her) as a result of the above-described accident. Releasor
intends that this release apply to any and all future injuries, damages, losses
and expenses, not now known or anticipated, but as may later develop or be
discovered, with all the effects and consequences thereof, arising out of the
This release shall fully and completely settle,
satisfy and discharge all of releasor’s claims, demands, actions and causes of
action against the parties hereby discharged under the Workers Compensation Law
of the State of ______________________, or any other law, arising or to arise
from the above-described accident.
All medical, hospital and other related expenses,
and all future medical, hospital and other related expenses that may be
incurred by releasor or any person in ___________ (his/her) behalf in
connection with the above-described accident are the sole and separate
obligation of releasor, and the parties named herein are released and
discharged from any and all liability therefor.
FOR EXECUTION OF RELEASE
Releasor states that no other promises have been
made or other considerations promised for the execution of this release and
settlement. Releasor executes this
release of _____ (his/her) own volition and free will and not on the advice or
statement of any physician, attorney or other person in any way connected with
the parties herein discharged as to any past, present or future condition of
fact of any kind or character whatever.
Releasor has read this release and fully understands
all its terms.
Releasor and company agree that this release will
not be effective unless and until it has been approved by
______________________________________________ (specify workers compensation
appeals board or by a referee).
In witness whereof, releasor executes this release
at ____________________ (designate place of execution) on the day and year
first above written.
Approved as to Form and Content By:
(Signature and Title of Official) (Date)