BEFORE THE MISSISSIPPI WORKERS' COMPENSATION COMMISSION
MWCC CLAIM NO.
CLAIMANT
VS.
EMPLOYER
AND
CARRIER
PETITION FOR APPROVAL OF SETTLEMENT UNDER
SECTION 71-3-29 OF MISSISSIPPI CODE, ANNOTATED
COMES NOW, Claimant, and having been joined by the Employer, and
Carrier, and files this Petition for Approval of Settlement and would show in support
thereof the following:
1.
Your Petitioner would show that in he/she was employed by at an average
weekly wage of $ . That on , while working for Employer he/she
slipped off of the rear bumper of a pickup while removing an overshot tool and injured his/her
.
2.
After the incident, Petitioner received medical services from , , ,
Mississippi .
3.
During the course of treatment of Petitioner performed arthroscopic surgery on the
injured and referred him/her for physical therapy.
4.
On , , established a % permanent partial disability to
Petitioner.
5.
Petitioner has been discharged by for the present injury.
6.
Your Petitioner would show that all medical records and reports known by the parties to
exist regarding the present injury are on file in this cause and are incorporated herein by
reference.
7.
Your Petitioner would show unto the Court that the Employer has paid benefits unto
Petitioner as follows: (a) Temporary Partial Disability Payments; $ (b) Medical
Payments; $
8.
Petitioner has agreed to settle this claim against Employer for the total sum of $ ,
with the Claimant being responsible for satisfying all out standing claims, if any, out of the
settlement proceeds, said sum to be in full, complete and final settlement of any and all claims,
including but not limited to, claims for medical that your Petitioner may now or hereafter have
against Employer in any way connected with the present injury occurring on , .
9.
Petitioner is aware of the hearing procedures afforded in such cases and the possibility
that he/she might receive an award of a greater amount or lesser amount than agreed herein if
this matter were adjudicated.
10.
Your Petitioner would further show unto the Commission that based on the facts as your
Petitioner is able to present them to the commission, your Petitioner feels that it would be in
your Petitioner's best interest that he/she be authorized and empowered to make said settlement,
that said sum would become a sum certain without discount and is not readily payable, and that
it would be to the best interest of your Petitioner that said settlement be approved and that your
Petitioner be authorized and empowered to accept said settlement offer in full, complete and
final settlement of any and all claims arising out of the , incident, be know or
unknown, which he may now have or hereafter have against the Employer, including but not
limited to, claims for medical because of or in any way connected with the incident occurring on
, .
11.
Your Petitioner would further show unto the Commission that based on the facts as your
Petitioner is able to present them to the Commission, your Petitioner feels that it would be in
your Petitioner's best interest that he/she be authorized and empowered to make said settlement,
that said sum would become a sum certain without discount and is not readily payable, and that
it would be to the best interest of your Petitioner that said settlement be approved and that your
Petitioner be authorized and empowered to accept said settlement offer in full, complete and
final settlement of any and all claims arising out of the incident occurring on , ,
whether said claims be known or unknown, which he/she may now or hereafter have against
Employer and Carrier and either of them, including but not limited to, claims for medical
because of or in any way connected with the incident occurring on , .
12.
Your Petitioner would further show unto the Commission that upon payment to your
Petitioner of the sum of $ , with the Claimant being responsible for satisfying all outstanding
medical bills, if any, out of the settlement proceeds, the Employer and Carrier shall stand forever
fully and finally discharged and acquitted of any other and further liability to your Petitioner and
any others for injuries by your Petitioner on , while in the employ of the Employer,
and of the effects thereof, whether known or unknown, and your Petitioner would further show
unto the Commission that he/she hereby be authorized and empowered to execute any releases,
receipts, and other instruments required by Employer and Carrier to evidence their complete
release, acquittance and discharge herein as to the , incident.
13.
Your Petitioner denies that he/she has received any Medicaid benefits for his/her alleged
injury and states specifically that any Medical benefits which may have been paid on his/her
behalf concern medical problems totally unrelated to the injuries for which claim has been made
herein. The Affidavit of Claimant regarding same is attached hereto as Exhibit "D" and
incorporated herein by reference.
14.
In further consideration of such payment, Petitioner agrees to never institute any action
against , Employer and , Carrier for alleged bad faith, alleged discrimination under the
American with Disabilities Act, or any other state or federal law; and to never institute any other
type of action against , Employer and , Carrier, arising in any manner from Petitioner's
work injury that has been estimated to have occurred , . In further consideration of
such payment, Petitioner acknowledges that Employer and Carrier have in no way discriminated
against, nor violated his/her rights under the provisions of 41 U.S.C. § 12101, et seq. , Title VII
of the Civil rights Act of 1964, 42 U.S.C. § 2000(e), et seq. , or the Rehabilitation Act of 1973 at
20 U.S.C. § 701 et seq.
WHEREFORE, PREMISES CONSIDERED, your Petitioner prays that this, his/her
Petition, be received and filed and that on a final hearing hereof, this Commission will enter an
Order authorizing and empowering your Petitioner to settle his/her claim against Employer and
Carrier, and either of them, at and for the sum of $ , with the Petitioner being responsible
for satisfying all outstanding medical bills, if any, out of the settlement proceeds, the payment of
said sum to be in full, complete and final settlement of any and all claims, whether known or
unknown, or unpaid, incurred or to be incurred, including, but not limited to, claims for medical
that he/she or any other entities may now or hereafter have against Employer and Carrier and
either of them arising out of the injury occurring on , and your Petitioner further
prays that he/she be authorized and empowered to execute any releases, receipts and other
instruments required by Employer and Carrier to evidence their complete release, acquittance
and discharge herein as to the , incident.
Respectfully submitted,
___________________________________
, CLAIMANT
APPROVED AND AGREED:
_______________________________________
AFFIDAVIT
STATE OF MISSISSIPPI
COUNTY OF
PERSONALLY appeared before me, the undersigned authority in and for the above
jurisdiction, the within named , who being by me first duly sworn, did depose and say:
That he/she is , of , Mississippi; that he/she is a person of the full age of majority;
that he/she has carefully read or has had read to him/her the Petition for Approval of Settlement
Under Section 71-3-29 of Mississippi Code of 1972, Annotated, to which this Affidavit is
attached in its entirety, and that he/she knows he/she has a right to a hearing before an
Administrative Judge of the Mississippi Workers' Compensation Commission for a
determination of the benefits, if any, to which he/she would be entitled as a result of his/her
injuries; that he/she understands that in such hearing he/she could be awarded a greater or lesser
amount than that for which he/she is agreeing to settle his/her case; that he/she understands that,
in addition to compensation benefits, he/she would be agreeing to settle his/her case; that he/she
understands that, in addition to compensation benefits, he/she would be entitled to medical
benefits under the Mississippi Workers' Compensation law and that, by the terms of this
settlement, he/she is also giving up his/her right to past and future medical benefits as
contemplated by the Mississippi Workers' Compensation Law; that he/she understands that if
this settlement is approved, he/she will not be entitled any other benefits under the Mississippi
Workers' Compensation Law as a result of this injury; that he/she is aware of his/her physical,
medical and mental condition; that he/she knows that doctors and other persons can make
mistakes, and that he/she is taking the risk that what his/her doctors have told him/her about
his/her present and future medical condition may be wrong, and if that should be the case, it is
his/her loss; that he/she has reached maximum medical improvement and has been given a
disability rating; that there are no pending surgeries or treatments to be done except treatment for
symptoms; that he/she is agreeing to finally and forever settle his/her case in exchange for the
consideration being paid to him/her as set forth in the Petition for Approval of Settlement and
has executed the Petition for Approval of Settlement Under Provisions of Section 71-3-29 of
Mississippi Code of 1972, Annotated, and this Affidavit as his/her own free act and deed; that
he/she agrees not to reopen or attempt to reopen this claim; that he/she fully understands the
terms of the settlement and asks that the Commission approve the settlement as proposed; that
he/she understands the Employer, and Carrier, deny that Petitioner has suffered any
permanent disability or that any disability resulted from the present injury, deny any liability
herein, and that by this settlement, the Employer and Carrier are buying their peace.
WITNESS HIS/HER SIGNATURE HERETO, this the day of , .
_____________________________________
SWORN TO and subscribed before me, this the day of , .
_____________________________________
NOTARY PUBLIC
MY COMMISSION EXPIRES: _________________________________
BEFORE THE MISSISSIPPI WORKERS' COMPENSATION COMMISSION
MWCC CLAIM NO.
CLAIMANT
VS.
EMPLOYER
AND
CARRIER
ORDER GRANTING SETTLEMENT
THIS CAUSE having come on this day to be heard before the commission on the
Petition of asking for authority to settle his/her Workers' Compensation Claim under the
provisions of Section 9(i) of the Mississippi Workers' Compensation Law, said petition having
been joined and approved by the Employer and Employer's attorney, the Commission, after
being fully advised in the premises, finds that Petitioner herein was employed by at an
average weekly wage of $ . That while working for Employer he/she slipped off of the rear
bumper of a pickup while removing an overshot tool and injured his right .
The commission further finds that after the incident Petitioner received medical services
from , , , Mississippi .
The commission further finds that established a % permanent partial disability to
Petitioner.
The commission further finds that during the course of treatment of Petitioner ,
performed orthoscopic surgery on the injured and referred Petitioner for physical therapy.
The commission further finds that Petitioner has been discharged by for the present
injury.
The commission further finds that all medical records and reports known by the parties to
exist regarding the present injury are on file in this cause and are incorporated herein by
reference.
The commission further finds that the Employer has paid benefits unto Petitioner as
follows: (a) Temporary Partial Disability Payments; $ and (b) Medical Payments; $ .
Petitioner has agreed to settle this claim against Employer for the total sum of $ , with
the Claimant being responsible for satisfying all out standing claims, if any, out of the settlement
proceeds, said sum to be in full, complete and final settlement of any and all claims, including
but not limited to, claims for medical that your Petitioner may now or hereafter have against
Employer in any way connected with the present incident occurring on , .
That Petitioner is aware of the hearing procedures afforded in such cases and the
possibility that he might receive an award of a greater amount or lesser amount than agreed
herein if this matter were adjudicated.
The Commission further finds that Petitioner feels that it would be in Petitioner's best
interest that he/she be authorized and empowered to make said settlement, that said sum would
become a sum certain without discount and is not readily payable, and that it would be to the
best interest of Petitioner that said settlement be approved and that Petitioner be authorized and
empowered to accept said settlement offer in full, complete and final settlement of any and all
claims arising out of the , incident, be know or unknown, which he/she may now have
or hereafter have against the Employer, including but not limited to, claims for medical because
of or in any way connected with the incident occurring on , .
The Commission further finds that Petitioner represents and acknowledges that he/she
has carefully read or has read to him/her the Petition for Approval of Settlement Under Section
71-3-29 of Mississippi Code of 1972, Annotated, and that he/she knows that he/she has a right to
a hearing before an Administrative Judge of the Mississippi Workers' Compensation
Commission for a determination of the benefits, if any, to which he/she would be entitled as a
result of his/her alleged injuries; that he/she understands that in such a hearing he/she could be
awarded a greater or lesser amount than that for which he/she is agreeing to settle his/her case;
that he/she understands that, in addition to compensation benefits, he/she would be entitled to
medical benefits under the Mississippi Workers' Compensation Law and that, by the terms of the
settlement, he/she is also giving up his/her right to past and future medical benefits as
contemplated by the Mississippi Workers' Compensation Law; that he/she understands that if
this settlement is approve, he/she will not be entitled to any other benefits under the Mississippi
Workers' Compensation Law as a result of his/her injuries; that he/she is aware of his/her
physical, mental and medical condition; that he/she knows that doctors and other persons can
make mistakes, and that he/she is taking the risk that what his/her doctors have told him/her
about his/her present and future medical condition may be wrong, and that if that should be the
case, it is his/her loss; that he/she is agreeing to finally and forever settle his/her case in
exchange for the consideration being paid to him/her as set forth in the Petition for Approval of
Settlement Under Section 71-3-29 of Mississippi Code of 1972, Annotated, and that he/she has
not been promised anything else; that he/she has agreed not to reopen or attempt to reopen this
litigation; that he/she voluntarily elected to settle his/her claim as set forth in Petition for
Approval of Settlement and executed the Petition for Approval of Settlement Under Provisions
of Section 71-3-29 of Mississippi Code of 1972, Annotated as his own free act and deed; and
that he fully understands the terms of the settlement.
The Commission further finds that Petitioner represents and acknowledges that he/she
has not received any Medicaid benefits for his/her alleged injuries and states specifically that any
Medicaid benefits which may have been paid on his/her behalf covering medical problems
totally unrelated to the injuries for which claim has been made herein.
The Commission further finds that it would be to the Petitioner's best interest that he/she
be authorized and empowered to make said settlement, that said settlement is just, fair and
proper and said settlement payment would be a sum certain without discount.
ORDERED AND ADJUDGED that and he/she is hereby authorized and empowered
to settle his/her claim against , Employer and , Carrier, at and for the sum of and
00/100 Dollars ($ ), with the Petitioner being responsible for satisfying all outstanding
medical bills, if any, out of the settlement proceeds, said sum to be in full, complete and final
settlement of any and all claims whether known or unknown, paid or unpaid, incurred or to be
incurred, and including, but not limited to claims for medical except for liability for Medicaid
under Code Section 43-13-125 incurred prior to the date hereof, specifically including but not
limited to medical expenses incurred prior to the date of settlement, that he/she may now or
hereafter have under provisions of the Mississippi Workers' Compensation Law against ,
Employer and , Carrier arising out of the present injury, with the Petitioner being responsible
for satisfying all outstanding medical bills, if any, out of the settlement proceeds, shall stand
forever fully discharged and acquitted of and from any and all claims including, but not limited
to, claims for medical, that Claimant or others may now or hereafter have against them jointly
and severally because of or in any way connected with Claimant's present injury, and the same is
hereby approved.
IT IS FURTHER ORDERED AND ADJUDGED that Petitioner is hereby authorized and
empowered to execute any releases, receipts, and other instruments required by Employer and
Carrier to evidence their complete release, acquittance, and discharge herein.
SO ORDERED AND ADJUDGED, this day of , .
MISSISSIPPI WORKERS' COMPENSATION COMMISSION
BY:______________________________
COMMISSIONER
______________________________
COMMISSIONER
_______________________________
COMMISSIONER
MWCC NO.
ATTEST:
_________________________________
, Secretary
BEFORE THE MISSISSIPPI WORKERS' COMPENSATION COMMISSION
MWCC CLAIM NO.
CLAIMANT
VS.
EMPLOYER
AND
CARRIER
RELEASE WITH COVENANTS
FOR AND IN CONSIDERATION of the sum of and /100 Dollars ($ ), with the
Claimant being responsible for satisfying all outstanding medical bills, if any, out of the
settlement proceeds, with same being paid by the Employer and Carrier, cash in hand paid to me
by , Employer and , Carrier, the receipt of which is hereby acknowledged, I the
undersigned, (hereinafter referred to as "Releasor"), do hereby forever fully release, acquit
and discharge , Employer and , Carrier, all of their employees, agents, successors, assigns,
representatives, officers, servants, heirs, insurer or insurers, subsidiaries, affiliates, and any and
all other person, firms, organizations, and/or corporations, and each and all of them whatsoever
related hereto having any liability in the premises, whether directly, indirectly or by contract,
vicariously or by way of indemnification (hereinafter referred to collectively as "Releasees") of
and from any and all actions, causes of action, claims, demands, damages, costs, expenses, loss
of services, accounts, covenants, contracts, controversies, trespasses, judgments, executions, loss
of consortium, loss of companionship, injuries, compensation, denial of compensation or
benefits, delay of compensation or benefits, claims for breach of insurance contract, property
claims, death claims, wrongful death claims, medical payments and compensation of every kind,
type and character whatsoever, upon, by reason of, on account of, as a result of any incident
which occurred on , at which time claims to have injured his/her when he/she
slipped off of the rear bumper of a pickup while removing an overshot tool while in the course
of his/her employment and while working for , it being the purpose and intent of this release
to include any and all injuries of any kind, character and description sustained by arising out
of or in any way associated with said employment with whether such injuries and damages
are known or unknown, whether they are presently existing or may arise in the future and
whether there by any mistake, either mutual or otherwise by any or all of the parties hereto, as to
the character, nature or extent of said injuries or damages occurring as a result of the incident on
, .
The above settlement shall operate as and shall be a complete accord and satisfaction and
is a full acquittance in consideration of a full and complete settlement of any and all claims for
damages and injuries or every kind, character and description, including but not limited to
claims for compensation and medical benefits under the Mississippi Workers' Compensation
Law and claims pertaining to denial or delay of compensation benefits and/or claims involving
alleged breach of the underlying insurance contract, sustained by arising out of or associated
with said incident in any way, whether herein specifically described or not, which he/she may
now or hereafter have on account of or in any way connected with the incident occurring on
, .
It is understood and agreed by and between the parties hereto that payment of the
aforesaid sum or any other consideration running to the Releasor or any other person is not an
admission of any liability by any party released herein or any party making payment, but that
liability for injury and damages to Releasor is specifically denied, the payment of the aforesaid
sum and any other consideration constituting settlement of a disputed claim.
In further consideration of such payment, the Releasor further acknowledges the
complete accord and satisfaction of all claims and demands heretofore made or that ever shall be
made against the Releasees herein in any way growing out of the occurrence occurring on
, or the injuries or damages of Releasor. It is understood, covenanted and agreed as part of
this settlement that the litigation pending before the Mississippi Workers' Compensation
Commission, styled, , Claimant, versus , Employer and , Carrier", and being
designated by MWCC Number on the docket of said Commission shall be dismissed with
prejudice and an appropriate Order approving settlement and dismissing said cause shall be
entered immediately. It is further understood, covenanted and agreed as part of this settlement
that any other litigation pending against the Releasees will be dismissed with prejudice as to any
rights or causes of action accrued or accruing to the Releasor or his/her heirs or assigns arising
out of the occurrence on , , and that an appropriate Order of Dismissal with Prejudice
will be entered as to any claim heretofore filed in such proceedings by the Releasor on behalf of
any parties, assigns, or heirs. Releasor further covenants and agrees as a part of this settlement
and for the consideration stated that he/she will assert no further claims against Releasees
regarding, concerning or arising out of the occurrence aforesaid; will not reopen or attempt to
reopen the aforesaid litigation or claims in any manner whatsoever; and will defend and hold
Releasees harmless in all respects as to the incident occurring on , .
In further consideration of such payment, the Releasor further agrees to never institute
any action against , Employer and , Carrier, for alleged bad faith, alleged discrimination
under the Americans with Disabilities Act, or any other state or federal law; and to never
institute any other type of action against , Employer and , Carrier, arising in any manner
from Releasor's alleged work injury which has been estimated to have occurred , . In
further consideration of such payment, Releasor acknowledges that Employer and Carrier have
in no way discriminated against, nor violated his/her rights under the provision of 42 U.S.C. §
12101, et seq. , Title VII of the Civil Rights Act of 1964, 42 U.S.C. § 2000(e), et seq. or the
Rehabilitation Act of 1973 at 20 U.S.C. § 701 et seq .
Releasor agrees, covenants and warrants that there have been no assignments or any right
or claim arising out of the occurrences, injuries, or damages to any persons, or entity not joining
in this release instrument and the Releasor agrees that hereafter, the Releasees shall be as free of
liability in the premises as if the aforesaid occurrence had never occurred.
The Releasor further covenants, agrees and warrants that he/she has not received from
the Division of Medicaid, in the Office of the Governor, State of Mississippi or other State
Division of Medicaid or under the federal Medicaid or Medicare provisions any benefits or
assistance paid for by said Division or other State Division of Medicaid or under said federal
provisions for medical assistance or medical services of any nature whatsoever provided to
him/her arising out of or in any way related to the incident aforestated, caused under any
circumstances which create a cause of action in favor of his/her against any person, firm or
corporation and the Releasor will defend and save the Releasees harmless in all respects
whatsoever.
The Releasor covenants, agrees and warrants that no assignments have been made to any
persons or organizations who do not join in this release, sharing in the consideration stipulated
herein and in all respects the undersigned will defend and save the Releasees harmless in all
respects whatsoever.
stipulates and warrants that he/she is of sound and disposing mind and memory that
he/she is above the age of twenty-one (21) years; that he/she has full authority and capacity to
execute this instrument; that his/her signature is binding; and that as to these things he/she will
further hold the Releasees harmless and indemnify them.
The Releasor warrants, covenants and agrees that no promise or inducement has been
offered except as herein set forth; that this Release with Covenants is executed without reliance
upon any statement or representation by the persons or parties released, or their representatives,
or physicians, concerning the nature and extent of the injuries and/or damages and/or legal
liability therefor; and that he/she warrants, covenants and agrees, as a further consideration and
inducement for this compromise settlement, that it shall apply to all unknown and unanticipated
injuries and damages resulting from said occurrences, casualties or events, as well as to those
now disclosed for which any claim might or could be made against the Releasees herein.
It is further understood and agreed that the aforesaid payment shall not, in any manner,
be construed as an admission of liability on the part of any party named herein, but that such
payment constitutes sole compromise settlement and accord and satisfaction of the disputed
claims of the Releasor; that the release is without reservation of any kind and character and
includes fully and completely any and all claims of any type which may have arisen or may
hereafter arise in favor of the undersigned and any other parties entitled under the law to recover
for any injuries and damages to Releasor; and that the Releasor will forever hold the parties
hereby released harmless from any future claim or expenses of any kind or character by reason
of the aforesaid occurrences of , and the resulting injuries and damages of Releasor.
WITNESS MY SIGNATURE, this the day of , .
___________________________________
, CLAIMANT
STATE OF MISSISSIPPI
COUNTY OF
PERSONALLY CAME AND APPEARED BEFORE ME, the undesigned authority in
and for said county and state, the within named , who being first duly sworn, states on his/her
oath that he/she had read the foregoing Release with Covenants and that after reading and
explanation, he/she fully understands the meaning and purpose of the Release in all of its forms
and provisions and that he/she has signed, executed and delivered this Release as his/her
voluntary act and deed on the day and year therein mentioned.
_____________________________________
, CLAIMANT
SWORN TO AND SUBSCRIBED BEFORE ME, this the day of , .
_____________________________________
NOTARY PUBLIC
MY COMMISSION EXPIRES:
________________________-
