HomeMy WebLinkAbout1992-12-01; City Council; Resolution 92-348t II
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RESOLUTION NO. 9 2 - 3 4 8
A RESOLUTION OF THE CITY COUNCIL OF THE
CITY OF CARLSBAD, CALIFORNIA,
AUTHORIZING THE EXPENDITURE OF FUNDS
FOR SETTLEMENT OF THE WORKERS
COMPENSATION CLAIMS OF CHRISTINE
CHRISTENSEN
WHEREAS, Mr. John W. Mullen, Defense Counsel for the City of Carlsbad in this
matter, has recommended a settlement of the Workers Compensation claims of Christine
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Christensen; and
WHEREAS, there are sufficient funds available in the Workers Compensation Self-
10 Insurance Fund to pay the settlement,
11 NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of
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Carlsbad, California, as follows:
1. That the above recitations are true and correct.
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2. That the expenditure of $16,500 from the Workers Compensation Self-
Insurance Fund is authorized for the settlement of said claims.
3. That the Council accept the Compromise and Release, attached hereto as
Exhibit 2.
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PASSED, APPROVED AND ADOPTED at a Regular Meeting of the City 1
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Council of the City of Carlsbad on the 1st day of DECEMBER 1992, by the following
4 AYES: Council Members Lewis, Kulchin, Larson, Stanton
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ABSENT: Council Member Nygaard 6
NOES: None
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11 11 ATTEST:
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14 ALETHA L. RAUTENKRANZ, .&? City Clerk
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"I..LI".V....dL. -..- 1"". ~- ~.
P-EASE SEE INSTRUCTIONS ON
REVERSE OF PAGE 2 BEFORE 0 DIVISION OF INDUSTRIAL ACCIDENTS
DEPARTMENT OF INDUSTRIAL RELATIO w CASE NO. 2) UNASSIG - COblPLETlNG FORM WORKERS' COMPENSATION APPEALS BOARD
SOCIAL SECURITY NO. 558-59-4828
CHRISTINE CHRISTENSEN P.O. BOX 1423, ENUMCLAW, WA 98022
APPLICANT (EMPLOYEE) ADDRESS
CITY OF CARLSBAD 1200 ELM AVENUE, CARLSBAD, CA 92008
CORRECT NAME OF EMPLOYER ADDRESS
HCM CLAIMS MANAGEMENT CORPORATION 3954 MURPHY CANYON RD. , #D205, SAN DIE(
CORRECT NAME OF INSURANCE CARRIER ADDRESS
1. The injured emplo ee claims that while employed as a POLICE OFFICER 1) 10-d-91 (OCCUPATION AT TIME OF INJURY)
on 2) 10-15-90 TO 10-15-91at CARLSBAD , CALIFORNIA, by tl
(DATE OF INJURY) 'CITy'RIGHT KNEE, RIGHT HIP, R?Cm SHOULDER,
(s)he sustained injury arising out of and in the course of employment to WRT-TE, RIGHT ELBOW. NE
(STATE WHAT PARTS OF BODY WERE INJURED)
2. The parties hereby agree to settle any and all claims on account of said injury by the payment of the sum of $ 16 500 00
to any sums heretofore paid by the employer or the insurer to the employee, less amounts set forth in Paragraph No. 6.
3. Upon approval of this compromise agreement by the Workers' Compensation Appeals Board or a workers' compensation judge and
accordance with the provisions hereof, said employee releases and forever discharges said employer and insurance carrier from a!
causes of action, whether now known or ascertained, or which may hereafter arise or develop as a result of said injury, including
liability of said employer and said insurance carrier and each of them to the dependents, heirs, executors, representatives, adm
assigns of said employee.
4. Unless otherwise expressly provided herein, approval of this agreement RELEASES ANY AND ALL CLAIMS OF APPLICANT'S DEPE
DEATH BENEFITS RELATING TO INJURY OR INJURIES COVERED BY THIS COMPROMISE AGREEMENT. The parties have co
release of these benefits in arriving at the sum in Paragraph No. 2.
5. Unless otherwise expressly ordered by a workers' compensation judge, approval of this agreement DOES NOT RELEASE ANY C
CANT MAY NOW OR HEREAFTER HAVE FOR REHABlllTATlON OR BENEFITS IN CONNECTION WITH REHABILITATION.
6. The parties represent that the following facts are true: (If facts are disputed, state what each party contends under Paragraph No. 1'
" 10-15-91
DATE OF BIRTH ACTUAL EARNINGS AT TIME OF INJURY LAST DAY OFF WORK DUE TO THIS INJURY
PAYMENTS MADE BY EMPLOYER OR INSURANCE CARRIER
TEMPORARY DISABILITY INDEMNITY WEEKLY RATE PERIODS COVERED
F1lT.T. SAT-ARY L.C. 4850
PERMANENT DlSABlLlTY INDEMNITY TOTAL MEDICAL AND HOSPITAL BILLS
$1 ,.260.00 & continuinq $12,384.47
BENEFITS CLAIMED BY fNJURED EMPLOYEE
PEG:I::::I:S $2:) C:i=:L1S GATES CP bLL PED!C=B SF= "LIS Tr_l rW-5 lU?l.!D" MEDICAL AND HOSPITAL BILLS PAID BY EMPLOYEE
10-15-91 TO PRESENT, APPLICANT RETIRED NONE
TOTAL UNPAID MEMCAL AND HOSPITAL EXPENSE ESTIMATED FUTURE MEDICAL EXPENSE
To Be Paid BY: APPLICANT - NONE KNOWN To Be Paid By: APPLICANT
THE FOLLOWING AMOUNTS ARE TO BE DEDUCTED FROM THE SETTLEMENT AMOUNT:
$
$ PAYABLE TO J PAYABLE TO
.$ PAYABLE TO $ PAYABLE TO
** PAYABLE TO see Be1ow 15 PAYABLE TO
LEAVING A BALANCE OF $ 16: 500.00 , less approved attorney fee (See Paragraph No. 9), payable to applicant. (If pa?
other than in a lump sum, or there is additional information, specify on separate page(s).) Less permanent disability advances paid to applicant to the date of
Order Approving Compromise and Release. 5-lb. pqs@: I> 9 0 W%A
i.>cl v <> 7:. fJ I932
DIA WCAB FORM 15 (REV. 1983) (PAGE 1) s -a=, ... c* ..,, , .*
" 9 7 302-50 I 8.
7. Liens not mentioned in Paragraph Nomre to be disposed of as follows: ~NnlRl'l- i
- '&
8. For the purpose of determining the lien cloim(s) filed for benefits paid pursuant to the Unemployment Insurance Code or for ber
by lien claimants defined in Labor Code Sec. 4903.1, the parties propose reduction of the lien claim(s) in accordance with formula
9. Applicant's (employee's) attorney requests a fee of $ 1 9 g80 O0 . Amount of attorney fee previously paid, if any, $ -
10. Reason for Compromise, special provisions regarding rehabilitation and death benefit claims, and additional information:
THERE EXISTS A DISPUTE REGARDING THE NATURE AND EXTENT OF DISABILITY AS WELL AS FUT
CARE. PARTIES WISH TO AVOID THE HAZARDS OF LITIGATION AND SETTLE FOR A LUMP SUM CE
APPLICANT DESIRES TO CONTROL HER OWN MEDICAL CARE. APPLICANT WAIVES INTEREST IF TH
IS PAID WITHIN THIRTY (30) DAYS OF JUDGE 'S APPROVAL.
AS PART OF THE CONSIDERATION FOR THIS COMPROMISE AND RELEASE, APPLICANT FOREVER REL:
THE DEFENDANT FROM ANY LIABILITY ARISING OUT OF FUTURE INJURIES THAT MIGHT OCCUR DUI
VOCATIONAL REHABILITATION AND ARE A COMPENSABLE CONSEQUENCE OF THE ORIGINAL INJURY.
(ROEEFS VS. lC-AI3 (1985) i 49 C"L, COW. CASES 561)
11. It is agreed by all parties hereto that the filing of this document is the filing of an application on behalf of the employee, and tl
may in its discretion set the matter for hearing as a regular application, reserving to the parties the right to put in issue any of the
herein, and that if hearing is held with this document used as an application the defendants shall have available to them all defe
available as of the date of filing of this document; and that the WCAB may thereafter either approve said Compromise Agreemel
or disapprove the same and issue Findings and Award after hearing has been held and the matter regularly submitted for decisior
WITNESS the signature hereof this day of ,19-,at .
WITNESS APP~ANT ?hJ&~)bM 0 ,I ;ob&
/) CHRLSTINE CHRISTENSEN
WITNESS
THE APPLICAWS (EMPLOYEE'S) SIGNATURE MUST BE ATTESTED BY TWO DISINTERESTED PERSONS OR ACKNOWLEDGED BEFORE A NOTARY PUBLIC.
STATE OF - tl, lh?&xU td
A.D., 19 4a, before me, ZC+~ 0 -2 o G
known to me to be
my hand and affixed my official seal the day and year in this Certificai written.
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DIA WCAB FORM 15 (REV. 1983) (PAGE 2)
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