Employee's Release from Personal Injury Claims (United States)
This is an employee release from personal injury claims. The form provided here is simply a sample of what the actual form looks like.
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.
A. Releasor has been employed by company as a
____________________________ (set forth job title or description) since
______________________ (month & day), _________ (year),
(earns the sum of ____________________ Dollars ($_________) per week or set forth average weekly wage as determined under workers compensation law).
B. On _____________________ (month & day), _________ (year), releasor sustained personal injuries, including
________________________________________________ (enumerate), as a result of an accident that occurred as follows:
C. The above-described personal injuries are ________________ (total or partial) and have been determined to be
_________________________ (permanent or temporary) in nature.
D. Prior to the date of this release,
_________________ (month & day), ______ (year),
the sum of __________________ Dollars ($__________) 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 ($__________) in additional payments is to be made to releasor,
such payments continuing until
________________________ (month & day), ___________ (year),
or for a period of ____________ weeks.
E. __________ (In the event of a claim or lien for unemployment benefits, the number of days and the amount of temporary disability indemnity for which a lien should be allowed should be set out.)
F. Releasor is willing to release company from all claims that
____________ (he/she) may have in relation to the above-described personal injuries according to the terms of this instrument.
RELEASE OF ALL CLAIMS
In consideration of the sum of ____________ Dollars ($__________ ), 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.
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.
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.
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.
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.
Approved as to Form and Content By:
(Signature and Title of Official)