HomeMy WebLinkAbout1995-05-16; City Council; Resolution 95-126i II 0 0
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I RESOLUTION NO. 95-126
I A RESOLUTION OF THE CITY COUNCIL OF THE
CITY OF CARLSBAD, CALIFORNIA,
AUTHORIZING THE EXPENDITURE OF FUNDS
FOR SETTLEI%ENT OF THE WORKERS
COMPENSATION CLAIMS OF CHRIS KOWALSKI
5 WHEREAS, Mr. Gary Bourassa, Defense Counsel for the City of Carlsbad in th
6 matter, has recommended a settlement of the Workers Compensation claims of Chris
7 11 Kowalski; and
a WHEREAS, there are sufficient funds available in the Workers Compensation Sf
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Exhibit 2. 17
3. That the Council accepts the Compromise and Release, attached hereto a!
Insurance Fund to pay the settlement,
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 $15,000 from the Workers Compensation Self-
Insurance Fund is authorized for the settlement of said claims.
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PASSED, APPROVED AND ADOPTED at a Regular Meeting of the Cit
Council of the City of Carlsbad on the 16th day of MAY 1995, by the following
vote, to wit:
AYES: Council Members Lewis, Nygaard, Kulchin, Finnila, Ha
NOES: None
ABSENT: None
ATESfi
&L%* hnw 2, City Clerk KAREN R. KUNDTZ, Assistant City Clerk
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EXHIBIT 2
COMPROMISE AND RELEASE STATE OF CALIFORNIA
PLEASE SEE INSTRUCTIONS ON DEPARTMENT OF INDUSTRIAL RELATIONS
REVERSE OF PAGE 2 BEFORE DIVISION OF WORKERS' COMPENSATION
COMPLETING FORM WORKERS' COMPENSATION APPEALS BOARD
CASE NO. SDo c
SOCIAL SECURITY NO. 31f-c
1050 HAZEN DRIVE
CHRIS KOWALSKI SAN MARCOS, CA 92069
APPLICANT (EMPLOYEE) 1200 CARLSBAD VILLEFDRIVE CITY OF CARLSBAD CARLSBAD, CA 92008
HERTZ CLAIMS MANAGEMENT SAN DIEGO, CA 92171
1. The Injured employee claims that while employed as a ' POLICE OFFICER
CORRECT NIME OF EMPLOYER P.O. BOX 710400 ADDRESS
CORRECT NAME OF INSURANCE CARRIER ADORES
(OCCUPATION ATTIME OF INJURY)
on 7/22/93 at CARLSBAD CA
(s)he sustalned Injury arising out of and in the course of employment to Lt* Shoulder, Lt. Upper Extremi Rt. thumb, both knees, both lower extremitiesy- TE WHAT PARTS OF BODY WERE INJURED
2, Tdalms on-he p ment of the sum of $ 15, 001
In addition to any sums heretofore paid by the employer or the Insurer to the employee, less amounts set forth in Paragra
(DATE OF INJURY) (CITY) (STATE)
- .&, b$Y-
3. Upon approval of thls compromlse agreement by the Workers' Compensatlon Appeals Board or a workers' compensation jud
In accordance wlth the provlsions hereof, said employee releases and forever dlscharges satd employer and Insurance
clalms and causes of action, whether now known or ascertalned, or whlch may hereafter arise or develop as a resul'
mcludlng any and all lrabtllty of sald employer and Said Insurance carrier and each of them to the dependents, hc
representatives, adminlstrators or assigns of said employee.
4. Unless otherwlse expressly provided herein, approval of this agreement RELEASES ANY AND ALL CLAIMS OF APPLICANT'S
DEATH BENEFITS RELATING TO INJURY OR INJURIES COVERED BY THIS COMPROMISE AGREEMENT. The parties have
release of these benefits in arrivtng at the sum in Paragraph No. 2.
5. Unless otherwlse expressly ordered by a workers' compensatlon judge, approval of thls agreement DOES NOT RELEASE !
CANT MAY NOW OR HEREAFTER HAVE FOR REHABILITATION OR BENEFITS IN CONNECTION WITH REHABILITATION.
6. The partles represent that the followlng facts are true: (If facts are disputed, state what each party contends undel
DATE OF BIRTH ACTUALEARNINGSATTIME OF INJURY LAST DAY OFF WORK DUE TO THI:
7/15/61 $836.37 PER WW IN DISPUTE
PAYMENTS MADE BY EMPLOYER OR INSURANCE CARRIER
TEMPORARY DISABILITY INDEMNITY WEEKLY RATE PERIODS COVERED
ALL PERIODS AD- COmr~n
PERMANENT OlSnBlLlrV INDEMNITY TOTAL MEDICAL AN0 HOSPITAL BILLS
$3,080.00 - FD ADVANCES
BENEFITS CLAIMED BY INJURED EMPLOYEE
BEGINNING AND ENDING DATES OF ALL PERIOOS OFF DUE TO THIS INJURY MEDICAL AND HOSPITAL BILLS PAID BY EMPLOYEE
IN DISPUTE UNKNOWN
TOTAL UNPAID MEDICAL AN0 HOSPITAL EXPENSE ALL BY APPLICANT, NONE ESTIMATED FUTURE MEDICAL EXPENSE ALL BY
Tone PaldBy: BY DEFENDANT EXCEPT PER PARAGRAPH 7 To Be PaldBy: NONE BY DEFENDAl
THE FOLLOWING AMOUNTS ARE TO BE DEDUCTED FROM THE SETTLEMENT AMOUNT:
$ 3 , 0 8 0 . 0 0 PAYABLE TO PD ADVANCES $ PAYABLE TO
$ PAYABLE TO $ PAYABLE TO
$ PAYABLE TO $ PAYABLE TO
LEAVING A BALANCE OF $ 11 I 920 00 , less approved attorney fee (See Paragraph NO. 9), payable to applicant. (I
be other than In a lump sum, or there IS additlonal Informatlon, speclfy on separate page(s). ) LESS ANY FURTHER PERMANENT DISABILITY ADVANCES TO THE DATE OF THE ORDE
DWC WCAB FORM 15 (REV. 19921 (PAGE 11
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7. Ltens not mentioned In Paragraph No, 6 are to be disposed of as follows: NONE
8 For the purpose of determlnmg the lien clalm(s) flled for benefits pald pursuant to the unemployment Insurance Code
furnlshed by lien claimants deflned In Labor code Sec. 4903.1, the parties propose reduction of the llen clalm(s) In a1
formulae attached.
9. Appllcant's (employee's) attorney requests a fee of $ &)(J- . Amount of attorney fee prevlously patd, If any,
10. Reason for Compromise, Special provislons regardmg rehabilitation and death benefit claims, and additional information:
SEE ATTACHED EXHIBIT "A"
INCORPORATED BY REFERENCE
11 It IS agreed by all partles hereto that the flllng of thls document IS the filing of an.application on behalf of the employ1
WCAB may In Its dlscretion set the matter for hearlng as a regular applicatlon, reserving to the parties the rlght to put
the facts admltted hereln, and that If hearlng IS held with this document used as an application the defendants shall hi
them all defenses that were available as of the date of filing of this document, and that the WCAB may thereafter eithl
Compromise Agreement and Release or disapprove the same and issue Findings and Award after hearlng has been held
regularly submttted for declsion.
Witness the signature hereof this /L{+h dayof b,? PI' ] J'
WITNESS
WITNESS
THE APPLICANT'S (EMPLOYEE'S) SIGNATURE MUST BE ATTESTED BY TWO DISINTERESTED
PERSONS OR ACKNOWLEDGED BEFORE A NOTARY PUBLIC.
STATE OF CALIFORNIA r JOSEPH W. RIPPINGER, I11
ATTORNEY FOR DEFENDANT
County of xl 'he5,-.
A
on thrs L.tb day of
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P\Pf I $1 AD.. 19 - 4s before me, Cut( Cle.;cc.r, \
a Notary Public in and for the said County and State, residing therein, duty commissioned and sworn, personally appeared-
~l>r;s kC;Lc,\ski
known to me to be the person 4 whose name apvqr s om Corn p r CJM\ S? Q & \ ec; :,e
subscribed to the within lnstrurnent, and acknowledged to me that-he- executed thk same.
IN WlTNESS WHEREOF, l have hereunto set my hand and affixed my official seal the day and year in this Certificate first above
wntfen. >- A .? ,-&U A- ;,,. ' . ,-:.7\. ,,!.-' , \% LUCI CL.L.SS%~ $ 7 sw 2
., .i .: ~ < :r" -tlc::,csj " 4.
DWCwcABFO~M 15 (REV, ,992) WAGEZI-. ,.?;/ " '." ",."': :'v'.'~xs~ ." /-
'" NotaIyPublc ~n and tor sad counryand State 01 Caidornla
a 0
RE: CHRIS KOWALSKI vs. CITY OF CARLSBAD
WCAB NO. : SDO 0194593
ADDENDUM OA1l
A dispute exists between the parties as to w, - -, liability for self-procured and future medi treatment, v, e+mAm+s, periods of tempor#
wish to avoid the hazards and uncertainties of and settle by the lump sum contemplated herein
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disability, permanent disability - .. The part
The settlement includes any claim for interest' up to twenty-fi
(25) days of the service of Order Approving Compromise and Relea upon defendants.
Applicant has been advised and fully understands that tC Compromise and Release agreement releases any and all claims of h
dependents to death benefits relating to the injury or injuri covered by this compromise agreement.
The applicant has been advised and fully understands that th Compromise and Release Agreement releases any claim of injur. either specific or cumulative, resulting from past or futu:
rehabilitation process which emanated from the injuries referred on page one, paragraph one of this agreement. This paragraph do' not contemplate settling other normal vocational rehabilitatil
benefits in the future as a result of the injury herein. Rodqe, vs. WCAB 50 CCC 299 (19851, Carter vs. Countv of Los Anqele:
(Weatherspoon) vs. St. Ferdinand's School and Constancio vs. LC
An eles C(,unty, 51 C.C.C. 255 (1986) and any subsequent nodifyir 1 CHRIS KOWALSKI, APPLICANT DATED: y{+G /s F
.. /? SCOTT O'MARA, APPLICANT IS A
DATED : 4-/l/4357