Common Contracts
1 similar Compromise and Release Agreement contracts
ContractCompromise and Release Agreement • August 1st, 1997
Alaska Department of Labor COMPROMISE & RELEASEAlaska Workers' Compensation Board AGREEMENT SUMMARYP.O. Box 25512, Juneau, Alaska 99802-5512 AWCB Case Number INSTRUCTIONS: Complete and attach to the front of a compromise and release agreement submitted to the Alaska Workers' Compensation Board. This form may not be used in place of or as a compromise and release agreement. 1. Employee's Name (Last, First, Middle Initial) 2. Insurer Claim Number 3. Injury Date 4. Address 5. Social Security Number City State Zip Code Telephone 6. Birthdate (Age) 7. Employee Attorney 8. Employer 9. Employer/Insurer Attorney 10. Insurer 11. Other Party or Attorney 12. Other Party or Attorney 13. Explain Relationship to Case 14. Explain Relationship to Case 15. How Did Accident Happen? 16. Describe Injuries. 17. Medical Reports: All medical reports in the parties' possession are attached. □ Yes □ No 18. Permanent Impairment Ratingsa. % of ¡ % of ¡ % of By Dr. , Employee's Physicianb. % of ¡ % of ¡
