Fill and Sign the Nj Workers Compensation 497319522 Form

JOHN LAWYER, ESQ. 12 MAIN STREET ANYWHERE, USA Attorneys for Petitioner _______________________________ JOHN DOE, (SS # [INSERT]) Petitioner, v. EMPLOYER, USA, Respondent. ________________________________ STATE OF NEW JERSEY NEW JERSEY DIVISION OF WORKERS = COMPENSATION DISTRICT OFFICE: [INSERT] C.P. No. [INSERT] AFFIDAVIT OF [INSERT] STATE OF [INSERT] : ss COUNTY OF [INSERT] : I, [INSERT], being of sound mind and body and being duly sworn to oath, says: 1. I am the Petitioner in the above captioned matter. 2. I was injured on the job while I was working for [INSERT] on [DATE]. 3. As a result of the workplace accident I suffered injuries to my left shoulder. My attorney will provide to the court various medical reports which indicate the treatment I had undergone to my shoulder. 4. To this day I still have pain in my shoulder which stems from this accident. My attorneys have informed me that a settlement has been negotiated and agreed to between my employer = s workers compensation insurance carrier. I have been informed that the terms of the settlement are as follows. It has been explained to me that the settlement is a A Section 20" settlement. I understand that means that once I settle my claim I can never again reopen it for any reason. I accept that condition of the settlement and completely understand it. I have had the opportunity to discuss the settlement with my attorney, John Lawyer, Esq. and he has fully explained to me the terms and ramifications of a A Section 20" settlement. 5. In terms of compensation, I have agreed to resolve my claim for a lump sum payment of $20,000.00. 6. With respect to deductions from the $20,000.00 amount, Mr. Lawyer has explained to me that I will be responsible for attorney fees which could be up to 20% of the amount recovered after expenses. I accept that fee provision and would ask the Court to award my attorney a 20% fee, after deduction for expenses. 7. With respect to expenses on my file Mr. Lawyer has indicated to me that the following expenses have been incurred by his firm to litigate my matter: Medical Records from [insert] $ 97.62 Independent Medical Evaluation 200.00 Orthopaedic Assoc. 200.00 Sports Medicine 600.00 TOTAL $1,097.62 0 . I acknowledge responsibility for these costs and at all times Mr. Lawyer made me aware of why these costs would be incurred. I understand that they were incurred so that my matter could be properly litigated. 9. I therefore ask that the Court approve payment of the above expenses on this file. 10. Taking the $20,000.00 settlement less expenses brings a net recovery to $18,902.38 and taking 20% of that amount comes to $3,780.48 in counsel fees. 11. I understand that by accepting the Section 20 settlement and by settling my case that I am foregoing my right to a trial in this matter. I wish to settle this case and I am fully aware of the circumstances surrounding settlement. 12. I am presently single and have never been married. I do not have any children and I have no dependents. 13. I ask the Court to approve the settlement as recited in this Affidavit and I further ask that my Affidavit be relied upon exclusively without the need for me to come to New Jersey for purposes of putting the settlement on the record. ______________________________ JOHN DOE Subscribed to and sworn before me this ____ day of October, 2000 ________________________________ Notary Public