Form Bwc 7242 – Fill Out and Use This PDF

Self-insured Joint Settlement

Agreement and Release

Instructions

•Please print or type

•Please ile completed application at the nearest regional ofice of the Industrial Commission of Ohio (IC.)

I, _____________________________________________and ______________________________________________agree to make

(the injured worker)	(the employer)
settlement in the amount of $ ______________________.

1.By agreeing to the above amount, I, the injured worker, forever release and discharge the employer; its oficers; employees; agents; representatives; successors and assigns; the IC; BWC; the Ohio State Insurance Fund; and all persons, irms or corporations from any and all self insured claims, demands, actions or causes of action incurred on or before the date of this agreement, which I now have (or I may later claim to have), whether known or unknown, developing out of my employment with this employer or any other employer.

2.The injured worker and employer also agree that if the above claim (or any other claim(s) being settled), were recognized or allowed prior to the date of this agreement, then the cost of all medical, pharmacy or hospital bills, nursing services, etc., iled with the em- ployer is the responsibility of the employer.

If such medical costs occurred before the date of this agreement, but not filed with the employer before the date of this agreement, the cost of those services shall be the responsibility of the injured worker. All costs of medical, pharmacy or hospital bills, nursing services, etc., provided to the injured worker on or after the date of this agreement is also the injured worker's responsibility.

3.The injured worker and employer agree to exclude the following claim (or claims) from this settlement:

4.Additional terms of this settlement agreement are:

The injured worker and employer have signed this inal settlement agreement on the date indicated and agree the effective date of this agreement is _________________________.

This date remains in effect unless denied by the IC within 30 days of the effective date, or the injured worker or employer withdraws this agreement within 30 days of the date of this agreement.

Injured worker signature		Date	Employer signature	Date
Current address			By:
City	State	Nine-digit ZIP code	State of Ohio - County

I, ___________________________, state that the injured worker personally appeared before me. The injured worker acknowledges the

execution of this agreement for inal settlement was made of his/her free will. The injured worker acknowledges this agreement between him/her and the employer will result in a complete and inal settlement of all claims listed in this settlement.

In witness thereof, I have set my hand and oficial seal, this _____ day of ____________________, 20 ____.

Notary public

I, ______________________________________, certify I am the attorney of record for this injured worker. Before signing this settle-

ment agreement, the injured worker either read the agreement or the agreement was read and explained to them. The injured worker stated he or she was satisied with this settlement.

Attorney of record signature

BWC-7242 (REV. 1/12/2005)

SI-42