Dwc Ca Form 10214 D – Fill Out and Use This PDF

STATE OF CALIFORNIA

DIVISION OF WORKERS' COMPENSATION

WORKERS' COMPENSATION APPEALS BOARD

COMPROMISE AND RELEASE

(Dependency claim)

Venue Choice is based upon: (Completion of this section is required)

Residence of employee (Labor Code section 5501.5(a)(1))

Location where injury occurred (Labor Code section 5501.5(a)(2))

Principal address of employee’s attorney (Labor Code section 5501.5(a)(3))

Select 3 Letter Office Code For Place/Venue of Hearing (From Document Cover Sheet)

Employee (Completion of this section is required)

First Name

MI

Last Name

Address/PO Box (Please leave blank spaces between numbers, names or words)

City

State

Zip Code

Employer (Completion of this section is required)

Name (Please leave blank spaces between numbers, names or words)

Address/PO Box (Please leave blank spaces between numbers, names or words)

City

State

Zip Code

DWC-CA form 10214 (d) (PAGE 1) (REV. 07/2008)

Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by claims administrator)

Insurance Carrier Name (Please leave blank spaces between numbers, names or words)

Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words)
City	State	Zip Code

Claims Administrator Information (if known and if applicable)

Name (Please leave blank spaces between numbers, names or words)

Street Address/PO Box (Please leave blank spaces between numbers, names or words)

City

State

Zip Code

1. The below - named dependent(s)

claims that

( NAME OF EMPLOYEE )

while employed at

on

Date of Injury: MM/DD/YYYY

by

, then insured as to worker's compensation liability

(NAME OF EMPLOYER )

by

sustained injury arising out of and in the course of such

(STATE NAME OF CARRIER OR WHETHER SELF - INSURED)

employment as follows:

4. Payments of compensation to the employee in his lifetime on the account of the claimed injury were

.

DWC-CA form 10214 (d) (PAGE 2) (REV. 07/2008)

5.The applicant(s) herein claims to have been dependent upon said employee at the time of the claimed injury and states the name(s), age(s), relationship to, and the extent of dependency upon the deceased employee to have been as follows:

Dependent # 1 of Employee

Dependent # 2 of Employee

Dependent # 3 of Employee

6. The parties hereby agree to settle any and all claims of said dependent(s) on account of the claimed injury and the death of said

employee by the payment of sum of $		, payable as follows to:

7.The parties hereby agree (if such items of expense be claimed) that medical, hospital and burial expense required by reason of alleged injury and death of employee shall be borne as follows:

DWC-CA form 10214 (d) (PAGE 3) (REV. 07/2008)

8. Is the Applicant Represented?:

Yes

No if "No", applicant is to sign and date below.

if "Yes", applicant’s representative is to complete the following and is to sign and date below.

Law firm or Company Name (If applicable)

Law Firm Number (If Applicable)

Attorney/Rep First Name

MI

Attorney/Rep Last Name

Street Address/PO Box (Please leave blank spaces between numbers, names or words)

City					State		Zip Code
who requested a fee of $		, having been previously paid $
9. Reason for compromise

10.The undersigned request that this compromise agreement and release be approved.

11.Upon the approval of this compromise agreement as provided by law, and payment in accordance with the provision of the said order of approval, said applicants and each of them do hereby release and forever discharge said employer and said insurance company of and from all claims, demands, actions or causes of action, of every kind or nature whatsoever on account of, or by reason of injury and death sustained as aforesaid by the employee, and in particular of any, all and every claim or cause of action which the undersigned, heirs, executors, representatives, and administrators may have had, now have, or shall hereafter have against said employer, said insurance carrier, and each of them under Division 4 of the Labor Code of the State of California.

DWC-CA form 10214 (d) (PAGE 4) (REV. 07/2008)

12.It is agreed by all parties hereto that the filing of this document is filing of an application on behalf of the applicant and that it may be set for hearing as a regular application, reserving to the parties the right to put in issue any of the facts admitted herein, and that if hearing is held with this document used as an application the defendants shall have available to them all defenses that were available as of date of filing this document, and that it may thereafter be approved, disapproved, or a decision issued after a hearing has been held and the matter regularly submitted.

13.For the purpose of determining the lien claim filed herein for the unemployment compensation disability and / or unemployment compensation benefits which have been paid under or pursuant to California Unemployment Insurance Code, the parties propose the following division of sum agreed upon for settlement and release of this case:

$				for temporary disability covering the period		to		.
$			for accrued medical expense paid or incurred by the employee.
				for future medical care.
$
$				for permanent disability.

(The above segregation must be fair and reasonable and must be based on the real facts of the case. There should be no attempt made to deprive the lien claimant of a reasonable recovery consistent with all amounts involved.)

Witness the execution hereof this______________ day of ______________________, ______________________, at

Attorney for Defendant

(Date)

DWC-CA form 10214 (d) (PAGE 5) (REV. 07/2008)

ACKNOWLEDGMENT

State of California

County of _____________________________)

On _________________________ before me, _________________________________________

(insert name and title of the officer)

personally appeared ______________________________________________________________,

who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature ______________________________	(Seal)

DWC-CA form 10214 (d) (PAGE 6) (REV. 07/2008)