Fill and Sign the Nc Workers Compensation Form

     KNOW ALL MEN BY THESE PRESENTS, That I, We, for the sole consideration of       dollars to be paid by       lease and forever discharge the             about the                   resulting in                   IN WITNESS WHEREOF I, We, have hereunto set my, our, hand(s). this-                                    AGREED TO:             By             By       The foregoing settlement is hereby approved this       day of       By       FORM No. T-3 NORTH CAROLINA INDUSTRIAL COMMISSION RALEIGH, NORTH CAROLINA RELEASE OF TORT CLAIM UNDER GENERAL STATUTES 143-291 et seq. I. C. File No. T- (Defendant ) the payment whereof being made under the provision of General Statutes 143-291 et seq., I, We, have released, and discharged and by these presents do for myself, ourselves, my, our heirs, executors, administrators and assigns re- , its officers, employees, servants and agents of and from any and all claims, demands, damages, actions, cause of action of whatever kind or nature. on account of an accident which occurred on or day of , at. (Describe briefly injuries and/or d-ge) I, We, understand that this release is made as compromise to avoid expense and to terminate all controversy and/or claims for injuries or damages of whatever nature, known or unknown, including future developments thereof, in any way growing out of or connected with said accident. I, We, agree that the sum paid is solely by way of compromise of a disputed claim, and it is therefore specifically agreed that this release shall be a complete bar to all claims or suits for injuries or damages of whatsoever nature resulting or to result from said accident. I, We, further understand that until this release is approved by the Industrial Commission and payment has been re- ceived by the claimant, that this release will not become effective. day of Witness Claimant Address Address Unit, Agency or Department APPROVED: Defendant a Attorney NORTH CAROLINA INDUSTRIAL COMMISSION Commissioner File four completed copies with the Industrial Commission