Workers’ Compensation Settlement Agreement
Complete this form to document a compromise and release agreement for a workers’ compensation claim.
Employee Full Name
*
First Name
Last Name
Employee Contact Information
*
Employer/Insurer Name
*
Employer/Insurer Contact Information
*
Claim or Case Number
*
Date of Injury or Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Description of Injury or Incident
*
Settlement Amount Agreed Upon (USD)
*
Summary of Settlement Terms (briefly describe the main terms of the agreement)
*
Do you acknowledge that you have read and understood the terms of this settlement and agree to the compromise and release?
*
Yes, I acknowledge and agree.
No, I do not agree.
Signature of Employee (or Authorized Representative)
*
Submit Agreement
Submit Agreement
Should be Empty: