Fill and Sign the County of Principal Place of Business of Employees Attorney Labor Code Section 5501 Form

DWC-CA form 10214 (d) (PAGE 1) (REV. 11/2008) Employee (Completion of this section is required) Employer (Completion of this section is required) 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) Select 3 Letter Office Code For Place/Venue of Hearing (From Document C\ over Sheet) County of residence of employee (Labor Code section 5501.5(a)(1) or\ (d).) County where injury occurred (Labor Code section 5501.5(a)(2) or (\ d).) County of principal place of business of employee’s attorney (Labor \ Code section 5501.5(a)(3) or (d).) Zip Code MI First Name Last Name Address/PO Box (Please leave blank spaces between numbers, names or wor\ ds) City Case Number 1 Case Number 2 Case Number 3 Case Number 4 Case Number 5 Zip Code City Address/PO Box (Please leave blank spaces between numbers, names or wor\ ds) Name (Please leave blank spaces between numbers, names or words) SSN (Numbers Only) State State Insurance Carrier Information (if known and if applicable - include eve\ n if carrier is adjusted by claims administrator) Claims Administrator Information (if known and if applicable) while employed aton liability by ( NAME OF EMPLOYEE ) Date of Employee Death: MM/DD/YYYY , while . . , as a result of the claimed injury. DWC-CA form 10214 (d) (PAGE 2) (REV. 11/2008) 1. The below - named dependent(s) claims that (STATE NAME OF CARRIER OR WHETHER SELF - INSURED) sustained injury arising out of and in the course of such employment as \ follows: 3. The actual weekly wages of the employee at the time of claimed injury\ were, average weekly wages (statutory) were 4. Payments of compensation to the employee in his lifetime on the accou\ nt of the claimed injury were by , then insured as to worker's compensation Zip Code State City Insurance Carrier Street Address/PO Box (Please leave blank spaces betw\ een numbers, names or words) Insurance Carrier Name (Please leave blank spaces between numbers, name\ s or words) Zip Code State City Street Address/PO Box (Please leave blank spaces between numbers, names\ or words) Name (Please leave blank spaces between numbers, names or words) Date of Injury: MM/DD/YYYY 2. The death of the said employee occurred on (NAME OF EMPLOYER ) Dependent # 1 of Employee 5. The applicant(s) herein claims to have been dependent upon said emp\ loyee 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 # 2 of Employee Dependent # 3 of Employee employee by the payment of sum of $ 6. The parties hereby agree to settle any and all claims of said depende\ nt(s) on account of the claimed injury and the death of said , payable as follows to: Extent of dependency Extent of dependency Extent of dependency DWC-CA form 10214 (d) (PAGE 3) (REV. 11/2008) First Name Last Name Relationship Age MI MI Relationship Age First Name MI Relationship Age First Name Last Name Last Name 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: Partial Total Partial Total Partial Total 8. Is the Applicant Represented?: 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. 10. The undersigned request that this compromise agreement and release b\ e approved. 11. Upon the approval of this compromise agreement as provided by law, a\ nd payment in accordance with the provision of the said order of approval, said applicants and each of them do hereby relea\ se 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 emplo\ yee, 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 o\ f them under Division 4 of the Labor Code of the State of California. DWC-CA form 10214 (d) (PAGE 4) (REV. 11/2008) Yes No Zip Code City Street Address/PO Box (Please leave blank spaces between numbers, names\ or words) Law firm or Company Name (If applicable) Law Firm Number (If Applicable) Attorney/Rep Last Name Attorney/Rep First Name MI who requested a fee of $ , having been previously paid $ 9. Reason for compromise State Law Firm/Attorney Non-Attorney Representative 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 partie\ s 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 th\ e defendants shall have available to them all defenses that were available as of date of filing this document, and that it may there\ after 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 u\ nemployment compensation disability and / or unemployment compensation benefits which have been paid under or pursuan\ t to California Unemployment Insurance Code, the parties propose the following division of sum agreed upon for settlement\ and release of this case: $ $ $ $ to (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 consi\ stent with all amounts involved.) DWC-CA form 10214 (d) (PAGE 5) (REV. 11/2008) Witness 1 (Date) Applicant (Employee) (Date) Witness 2 (Date) Attorney for Applicant (Date) Interpreter (Date) Attorney for Defendant (Date) (Date) Attorney for Defendant (Date) Attorney for Defendant (Date) Attorney for Defendant for temporary disability covering the period for accrued medical expense paid or incurred by the employee. for future medical care. for permanent disability. . Witness the signature hereof this ________ day of ______________, ____\ ____________ at ______________________ DWC-CA form 10214 (d) (PAGE 6) (REV. 11/2008) 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/t\ hey executed the same in his/her/their authorized capacity(ies), and that by his/her/their sign\ ature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, e\ xecuted the instrument. I certify under PENALTY OF PERJURY under the laws of the State of Califo\ rnia that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature ______________________________ (Seal)