HomeMy WebLinkAbout1995-02-14; City Council; Resolution 95-39i e 0
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RESOLUTION NO. 9 5 - 3 9
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 RALPH GONZALJ2.S
5 WHEREAS, HCM Claim Management, the City's Third Party Administrator, has ' recommended a settlement of the Workers Compensation claims of Ralph Gonzales; and
7 11 WHEREAS, there are sufficient funds available in the Workers Compensation Se.
8 /I Insurance Fund to pay the settlement,
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NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of
Carlsbad, California, as follows:
1. That the above recitations are true and correct.
2. That the expenditure of $33,500.00 from the Workers Compensation Self-
Insurance Fund is authorized for the settlement of said claims.
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3. That the Council accept the Compromise and Release, attached hereto as
Exhibit 2.
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1 PASSED, APPROVED AND ADOPTED at a Regular Meeting of the City
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vote, to wit: 3
Council of the City of Carlsbad on the 14th day of FEBRUARY 1995, by the following
4 AYES: Council Members Lewis, Nygaard, Kulchin, Finnila, J&
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NOES: None
ABSENT: None
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ALETHA L. RAU
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,-CI3MP.RQMISE AND RELEASE e STATE OF CALIFORNIA
OEFARTMENT OF INOUSTRIAL RELArlONS EXHIBIT 2
PLEASE SEE INSTRUCTIONS ON REVERSE OF PAGE 2 BEFORE DIVISION OF INDUSTRIAL ACCIDENlS ..a .CASE NO. Unassiq CG'MPLETING FORM WCRKEAS' COMPENSATION APPEALS BOAR0
SOCIAL SECURITY NO. 556-04:
Ralph Gonzales ".- "- 417 Associated Rd., A232, Brea
City of Carlsbad 1200 Carlsbad Village Dr., Carlsbad,
Hertz Claim Management P.O. Box 710400, San Diego, CA
IP.LICAI.r ILLPt'IVCCI ""-
.OCP€SS
" - - . __ -. comnccr NAYS oc CY*COTCO lOCYI5S
C3lrSCT 5AYf OC **$CIAW-L CAmI)ItR "
AI)ORtSS
1. The injured employee claims that while employed as a Utility Systems Operator 111 ~CCLPIIC'W ar VUL oc IUJ~OWVI
0.1-3-90 & 10-29-91 d Carlsbad CA
(3**€ OS IUJURVI ICt-T! IS'.'*, .t
(s)he sustained injury orising out of and in the cowe of employment to -backd(r)Qkle
IST*It *-A? *AWTS OS 8001 WEDL ou).mfoj
2. The parties hereby agree to settle my and 011 claims on account of sard injury by thc paymevt of the sum of f -3& 5 0 0 0 0
to ony sums heretdore potd by I!le empioyer or the insurer tG the omploy-e. less o.~:n*r~*g set forth in Poroqraph No. 6
3. Upon opprovol of this ccmpromi:. ggreemcnt by the Workers' Conrpenrut;on Appeal$ hard or a workers' compenration judge
accordance with the provtrionr hereof, said cmployce releases and forever dischr~*ges soid rmployer and insurance carrier from
causes of action, wherher now known or ascertained. or which may h .reafter (3r'e.e or develop os a result of soid injury, includl
1.abllity of soid cnrp!opr and scud inwr;lnce carrier ocd eoch of them ts the dependents. hcirc. executors, repre5entotiver. a'
assigns ci said employee.
A IJnles% otherwire cxprridy provided here*-, approval of this agreemcnt RELEASE5 ANY AN9 ALL C141MS OF APPLICANT'S DE
DEATH SESEFITS RELATING TO INJiJRY OR INJUR!tS COVERED RY -!{IS COkfPROMI'.E 4G;EEMENT. The parlors ~OVC
releore of these bcnefrtr io orrivmg gt the sum rn Paragraph No. 2
5. Unless otherwise expressly ordered by o workers' cornpenrutton judge. upprovd of tht\ clytecnlent DOES NOT 4ELt'ASt ANY
CANT MAY NOW OR t3EREAfTER HAVE FOR RFhAt?lllTXTiON OR BENEFITS IN CONNECTlON WITH REt4ABllI~ATiC?N
6. The parties represent thot the following facts ore true: (If facts are disputed, state what eorh poet con!ends under Parrlgroph No.
9-12-56 $543.41 & 576.44 _."_ ~ """""._ 6-18-90 & 12-11-91
0411 Or 0111W ACIUAL EA*II.IWG1 .I 1.Y) 'C %IUIV < .sr rav OFF WOP. OUE -3 *-IS I.(.#.
PAYMENTS MADE BY EMPLOYER OR INSURANCE CARRIER
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TFYCO*I*V O'SAOILllT INOLYWlT W*LELRLV 0.1s Vf1)~001 r-5, LYE0 "_ """
lO56.00,6308.00 336.00, 266.00 10/30/91 - 11/17/91! 1/7/90-6/18/90, 12/9/91-12/13
13,370.00. 1920.00 23.089.05, 4755.05 " -
r&mY.*CNT DSA.ILI1T 8UMYWIV TOTAL YEWAL AUO M0SC'l.L m'LLS
BENEFITS CUIMED BY INJURED EMPLOYEE
Same as above none known
mg(;rsr*U, 1UO LNOlffi OAILS OS ALL OCPIOOS OF= DUE TJ IUIS 8UJU-T YE0'C.L 4+Cl rCS*'VaL CILLS ?An0 OT IYVLO'Et
701.~ UW-~IO YE0IC.L AUO *OSD.TAL LI*EIISL ESllualLD 'i.":9E Y#PCIL ELPEUSL
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To Ik. hid Py: All authorized care has ->id T<b nt' I'.llCl I;).' Applicant
THE FOLLOWING AMOUNTS ARE TO BE DEDUCTED FROM THE SETTLEMENT AMOUNT: Any and all permanen
5 15 t 290 00 PAYABLE TO defendant, PDA's -J PAY 4 6LE TO ___ "
I PAYABLE TO ___-__-. 5 "_ PAYABLE TO -.______
f PAYABLE ro f -- P4YABLE TO
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advances 1
LEAVING A BALANCE OF $ 19 I 335 * Lo, less opprcved anorney fee (See Paragraph No. 9'1. payable to oppltcmt. {If PC
other thon in a llJmp sum, or there is additional information, spectiy on separate poge;si.) *Advances Of 13,370.00 for date of injury 1/3/90 Advances Of 1,920.00 for date of injury 10/29/g1
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\ '. 7. L,mr yt mentioned in Parcgroph No. 6 are !o be disposed of OS follows: --- None ""- ..
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8 For the purpose of*deterrnining ?he lien cloim(s) filed for bcnefih paid pursuant to the Unemployment Insurance Code or for bc
by lien cloimanh delined in Lobor Code Sec. 4903.1. the paHiec propose reduction of the lien claim(s) in accordance with formu
9. Applkont'r (employe's) attomy qesh 0 fee Of s
0. &ason fw Compromise. spcrioi provi- regardii rehabilitation ond death benlit claims. and additional iniormation:
N/A . Amount of attorney fee previously poid, if any, $ - N
Applicant desires to control his own medical care, and understands this settlement re
Hertz Claim Manageaent and City of Carlsbad from the provision of any further benefit
medical treatrrrent.
The applicant desires a lunp sum settlement and both parties wish to avoid the hazarc of further litigatlon.
Defendant will be entitled to credit for all permanent disability advances paid to aF
through date of Order Approving the Compromise and Release, unless otherwise specifit
Applicant acknowledges that this settlement includes, settles and is in Consid-atioI all rights of his depenaentS.to death benefits which may arise from the injuries or c claimed herein.
Interest is waived if proceeds of the Compromise and Release are paid within twenty I
of receipt of Order of Approval.
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1 It is ogreed by oll pa~~es hereto ?hot the filing of *has document IS the Ihg cf an oppllcohon on behalf of the rwplay-e. ac
moy in its dircret~on set the matter for heoring as a regular application. reserving to the polher !he rqht to put in 's:u* ony ol
herein, ond thd if heortng 1% held with this document used a5 an opplicatlon the defendacts sholl hove avoJoble to them 011 (
oratlobte os .rf the dote of !ding of this document. and thot the WCAB moy thpreofter cather oppro',e soad Cc.nrFrornt,e Agre
or disapprove he some ond issue Findings and AworJ after heorang hos been held and the mower regvlorly tut.mtned for de(
I~IT\~.S rhc signa .of this [4m clfltJ'J/ JGd - " . 1!1 235- . fat AZE?+h
u - Gonzales "4 fl&"CYm
n * IS.
Tra &M<.-T S ICMDt.Oll~ $1 S8Gk.T-a vvlr 81 .TT#lT.1 8- WO P)r*.VS*IST#D Plm.Ol* OR aC.wc~a.DCE0 mES0.6 a ->Tam- hMC Barbara Stokes -HCM Claim M
5T:\TF. OF ~~.~l~l~OflSlA
c *rmnt y of San Diego I
t !rl this dl1 y nf .4.D.. 1.0 -. I"fr)lP Wt..
1 .vt,t,Jry flthlir in and for ti~v void C:orrnty nnrl Stnfr, rcsidtng f/tt+wrtt. ddg ~.~~r~~~~~~~~t~~~!~~~~ c:td worn. pcrsjmnlly qI;w
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,'V \\-IT.'\'ES.'i n'liEnKoF. I11,11t* lt(*rt*urtto *I*[ nly lttlttcl clnfl rljjittd ?III/ (,!'\:a I,:! u.111 t/:a. rIt;Id tlttr! !datir lrt this Ct.r
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