Fill and Sign the Claims Personal Form

Release of Claims for Personal Injuries by Employee Release executed on __________________ (date) , by ________________________ (Name of Releasor) , of _____________________________________________ (street address, city, county, state, zip code) , referred to herein as Releasor , to ________________________ (Name of Employer) , a corporation organized and existing under the laws of the state of ________________________ (name of state) , with its principal office located at ________________________________________ (street address, city, county, state, zip code) , referred to herein as the Company. Whereas, Releasor has been employed by Company as a __________________ (title of Releasor) since __________________ (date) , and earns $ __________________ per week; and Whereas, on __________________ (date) , Releasor sustained personal injuries, including _____________________________________________ (description of injuries) , as a result of an accident that occurred as follows: _____________________________________________ (description of accident) ; and Whereas, the above-described personal injuries are __________________ (total/partial) and have been determined to be __________________ (permanent/temporary) in nature. Whereas, prior to the date of this Release, __________________ (date of Release) , $ __________________ ________________________ (has been paid/is due and unpaid) to Releasor as benefits under the ________________________ (name of state) workers' compensation law. ________________________ (Text dollar amount of additional payments) dollars in additional payments is to be made to Releasor, such payments continuing until ________________________ (end date) , or for a period of ________________________ (number) weeks; and Whereas, Releasor 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; Now, therefore, for and in consideration of $ __________________ and the mutual covenants contained in this Agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: I. Release of all Claims. Releasor executes this Release in full settlement of all claims as set forth below in this Release. 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 of the same, arising out of the above-described accident. II. Workers’ Compensation. T his Release shall fully and completely settle, satisfy and discharge all of Releasor's claims, demands, actions and causes of action against the parties discharged by this Release under the workers' compensation law of ________________________ (name of state) , or any other law, arising or to arise from the above-described accident. III. Medical Expenses. 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 Company is released and discharged from any and all liability for the same. IV. Reliance 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 now 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. V. Approval. Releasor and Company agree that this Release will not be effective unless and until it has been approved by ________________________ (name of workers' compensation board) . WITNESS my signature as of the day and date first above stated. ____________________________ (Signature of Releasor) _____________________________ (Printed Name of Releasor)