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Form #668

Employee's Release - Personal Injury Claims

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Employee's Release - Personal Injury Claims (free form to use)

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EMPLOYEE'S RELEASE

PERSONAL INJURY CLAIMS

 

Release executed on _______________________ (month & day), _________ (year), by ___________________________ (name) ___________________________________

(address), here referred to as releasor, to ____________________________________ (name), a corporation incorporated under the laws of the State of _________________, of (or, if a corporation: with its principal place of business located at) ______________

______________________________________ (address), here referred to as company.

 

RECITALS

 

A.  Releasor has been employed by company as a ____________________________ (set forth job title or description) since ______________________ (month & day), _________ (year), and __________ (earns the sum of ____________________ Dollars ($_________) per week or set forth average weekly wage as determined under workers compensation law).

 

B.  On _____________________ (month & day), _________ (year), releasor sustained personal injuries, including ________________________________________________ ______________ (enumerate), as a result of an accident that occurred as follows:  _____________________________________________________________ (describe).

 

C.  The above-described personal injuries are ________________ (total or partial) and have been determined to be _________________________ (permanent or temporary) in nature.

 

D.  Prior to the date of this release, ______________________ (month & day), ______ (year), the sum of __________________ Dollars ($__________) has been paid (or is due and unpaid) to releasor as benefits under the _________________ (state) workers compensation law or otherwise as the case may be).  The sum of __________________ Dollars ($__________) in additional payments is to be made to releasor, such payments continuing until ________________________ (month & day), ___________ (year), or for a period of ____________ weeks.

 

E.  __________ (In the event of a claim or lien for unemployment benefits, the number of days and the amount of temporary disability indemnity for which a lien should be allowed should be set out.)

 

F.  Releasor is willing to release company from all claims that ____________ (he/she) may have in relation to the above-described personal injuries according to the terms of this instrument.

 

SECTION ONE

RELEASE OF ALL CLAIMS

 

In consideration of the sum of ____________ Dollars ($__________ ), receipt of which from company is hereby acknowledged, releasor executes this release in full settlement of all claims as hereinafter set forth for ______________________ (himself/herself), and ____________ (his/her) dependents, heirs, legal representatives and assigns, releasor forever releases and discharges company, its agents, officers, employees, successors and assigns, of and from any and all claims, demands, actions and causes of action or suits at law or in equity for and on account of any and all known and unknown injuries, disabilities, physical and mental, diseases, damages, losses and expenses sustained by _____________ (him/her) or anyone claiming under ____________ (him/her) as a result of the above-described accident. Releasor intends that this release apply to any and all future injuries, damages, losses and expenses, not now known or anticipated, but as may later develop or be discovered, with all the effects and consequences thereof, arising out of the above-described accident.

 

SECTION TWO

WORKERS COMPENSATION

 

This release shall fully and completely settle, satisfy and discharge all of releasor’s claims, demands, actions and causes of action against the parties hereby discharged under the Workers Compensation Law of the State of ______________________, or any other law, arising or to arise from the above-described accident.

 

SECTION THREE

MEDICAL EXPENSES

 

All medical, hospital and other related expenses, and all future medical, hospital and other related expenses that may be incurred by releasor or any person in ___________ (his/her) behalf in connection with the above-described accident are the sole and separate obligation of releasor, and the parties named herein are released and discharged from any and all liability therefor.

 

SECTION FOUR

RELIANCE FOR EXECUTION OF RELEASE

 

Releasor states that no other promises have been made or other considerations promised for the execution of this release and settlement.  Releasor executes this release of _____ (his/her) own volition and free

will and not on the advice or statement of any physician, attorney or other person in any way connected with the parties herein discharged as to any past, present or future condition of fact of any kind or character whatever.

 

Releasor has read this release and fully understands all its terms.

 

SECTION FIVE

APPROVAL

Releasor and company agree that this release will not be effective unless and until it has been approved by ______________________________________________ (specify workers compensation appeals board or by a referee).

 

In witness whereof, releasor executes this release at ____________________ (designate place of execution) on the day and year first above written.

 

 

_____________________________________                      ____________________

(Signature)                                                                                                        (Date)

 

(Acknowledgment)

 

 

Approved as to Form and Content By:

 

_____________________________________                      ____________________

(Signature and Title of Official)                                                                 (Date)

 

Contributed by
Vacuum Technologies LLC
 
Name of Firm Vacuum Technologies LLC
Total Forms Contributed 53
 

See All Vacuum Technologies LLC's Forms
 

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Terms Of Use

Submissions to this site, including any legal or business forms, posts, responses to questions or other communications by contributors are not intended as and should not be construed as legal advice. You are strongly encouraged to consult competent legal council before engaging in any action based upon content contained on this site.

These downloadable forms are only for personal use. Retransmission, redistribution, or any other commercial use is prohibited. This includes reposting forms from this site to another site offering free legal or other document forms for download.

Please note that the donator may have included different usage terms regarding this form, and you agree to abide by these terms. It is highly recommended that you have a licensed attorney review any legal documents for which you are searching in order to make sure that your needs are being properly and completely satisfied.

Your use of this site constitutes your acceptance of our terms of use and your agreement to hold this site, its officers, employees and any contributors to this site harmless for any damage you might incur from your use of any submissions contained on this site. If you do not agree to the above terms, please do not proceed.

These forms are provided to assist business owners and others in understanding important points to consider in different transactions. They are offered with the understanding that no legal advice, accounting, or other professional service is being offered by these documents or on this website. Laws vary in the different states. Agreements acceptable in one state may not be enforced the same way under the laws of another state. Also, agreements should relate specifically to the particular facts of each situation. Therefore, it is important to consult legal counsel whenever utilizing these forms. The Forms are not a substitute for legal advice YourFreeLegalForms.com is not engaged in recommending or referring members on the site or making claims about the competence, character or qualifications of its participating members.
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