Legal WC Letter

Legal WC Letter

Claimant Name:    Employer/Insurer Name:

Date of Injury:    Claim Number:    Policy Number:

Recitals

WHEREAS, Claimant alleges an industrial injury arising out of and in the course of employment on or about resulting in claims for medical treatment, temporary disability, permanent impairment, or other benefits; and

WHEREAS, Employer/Insurer acknowledges the Claimant sustained the above-described injury and has investigated the claim through claims handling and medical review; and

WHEREAS, the parties desire to resolve all disputes and claims arising from the injury without further litigation or administrative hearing, subject to the terms and conditions set forth herein.

NOW THEREFORE, in consideration of the mutual covenants and agreements contained herein, the parties agree as follows:

1. Definitions

For purposes of this Letter, the following definitions apply: "Claim" means all claims, demands, causes of action, and liabilities arising out of the described injury; "Effective Date" means the date of full execution by all parties as recorded in the signature block below.

2. Acknowledgment of Claim

Employer/Insurer acknowledges receipt of notice of the Claim and confirms claims investigations were conducted. This Letter documents the parties' agreement to resolve the Claim and does not constitute a judicial determination of liability.

3. Settlement Payment

Payment shall be made in a single lump sum by Employer/Insurer payable to Claimant or Claimant's counsel within days of the Effective Date. Any agreed allocation between medical and indemnity shall be as follows:

4. Release of Claims

Upon receipt of the Settlement Amount, Claimant hereby fully and forever releases and discharges Employer/Insurer, its past and present parents, subsidiaries, affiliates, agents, representatives, attorneys, employees, and insurers from any and all claims, demands, actions, causes of action, obligations, damages, and liabilities of any kind or nature, whether known or unknown, foreseen or unforeseen, which Claimant has or may have relating to the injury described above, including but not limited to medical expenses, temporary and permanent disability, vocational rehabilitation, or other benefits under applicable workers' compensation law.

5. Medical Benefits and Liens

The parties agree that payment allocation to medical expenses shall follow the allocation set forth above. Claimant certifies to the best of Claimant's knowledge that all known medical providers and other lien holders have been identified to Employer/Insurer. To the extent any medical lien exists, Claimant agrees to cooperate in resolving and satisfying such lien out of the proceeds as required by law or as otherwise agreed.

6. No Admission of Liability

This Letter is a compromise settlement of disputed claims and shall not be construed as an admission of liability, fault, or wrongdoing by Employer/Insurer. Employer/Insurer expressly denies any liability and enters into this agreement solely to avoid further expense and distraction.

7. Indemnification

Claimant agrees to indemnify and hold harmless Employer/Insurer from and against any claims, liens, or demands asserted by third parties, including medical providers or subrogated insurers, to the extent such claims relate to payments made under this Letter and to the extent required by applicable law.

8. Notices

Notices shall be deemed given when delivered in person or three days after deposit in the United States mail, postage prepaid, addressed to the parties at the addresses set forth above or at such other addresses as a party may designate in writing in accordance with this section.

9. Amendments; Waiver

This Letter may be amended, modified, or supplemented only by a written instrument executed by both parties. No waiver of any provision shall constitute a waiver of any other provision, nor shall any waiver be deemed a continuing waiver.

10. Governing Law

This Letter shall be governed by and construed in accordance with the laws of the state in which the injury occurred, without regard to principles of conflicts of law. Any action to enforce this Letter shall be brought exclusively in the appropriate court or administrative forum of that state.

11. Entire Agreement

This Letter constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations, and understandings, whether oral or written.

12. Severability

If any provision of this Letter is held to be invalid, illegal, or unenforceable, the remaining provisions shall remain in full force and effect and shall be interpreted so as to give effect to the original intent of the parties to the maximum extent permitted by law.

13. Counterparts and Electronic Signatures

This Letter may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. Signatures transmitted by electronic means shall be deemed binding for all purposes.

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