HomeMy WebLinkAbout1995-02-14; City Council; 13023; SETTLEMENT OF WORKERS' COMPENSATION CLAIMS OF RALPH GONZALESa
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SE?TLEMENT OF WORKERS’
Adopt Resolution No. 95 -37 approving the Compromise and Release which authorizes th
payment of $33,500.00 to Ralph Gonzales.
ITEM EXPLANATION
The claimant is a former Utilities Systems Operator I11 in the UtilitiesMaintenance
Department. He had been employed by the City since January 12, 1981 until his resignatic
Mr. Gonzales was injured on January 3, 1990 when he was assaulted while fixing an electri
box. He was again injured on October 29, 1991 when he slipped and fell down a flight of
The terms and conditions of the proposed settlement are set forth in the Compromise and
Release (Exhibit 2). The terms and conditions were agreed upon by Mr. Gonzales and by
HCM Claim Management, the City’s Third Party Administrator.
FISCAL, IMPACT
The total cost of the settlement is $33,500.00. There are sufficient funds available in the
worker^' Compensation Self=Imwance Fund to cover the cost of this settlement.
1. Resolution No. Ct 5 3‘7
2. Compromise & Release
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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 GONZALES
WHEREAS, HCM Claim Management, the City's Third Party Administrator, h;
recommended a settlement of the Workers Compensation claims of Ralph Gonzales; ar
WHEREAS, there are sufficient funds available in the Workers Compensation $
Insurance Fund to pay the settlement,
NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of
Carlsbad, California, as follows:
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That the above recitations are true and correct.
That the expenditure of $33,500.00 from the Workers Compensation Se
Insurance Fund is authorized for the settlement of said claims.
That the Council accept the Compromise and Release, attached hereto
Exhibit 2.
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PASSED, APPROVED AND ADOPTED at a Regular Meeting of the Ci,
Council of the City of Carlsbad on the 14th day of FEBRUARY 1995, by the following
vote, to wit:
AYES:
NOES: None
ABSENT: None
Council Members Lewis, Nygaard, Kulchin, Finnila,
ATTEST:
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ALETHA L. RAU
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EXHIBIT STA~E OF CALIFORNIA 0 CASE NO.-
SOCIAL SECURITY NO. 556-
OEPARTMFNT OF INOUSTRIAL RELAIK)NS
OIVISION OF IHOUSTRIAL ACCIDENTS
WCRNERS COMPENSATION APPEALS BOAWO
i) C.r)MPJZOMISE AND RELEASE
PLEASE SEE INSTRUCTIONS ON
QEVERSE OF PAGE 2 eEFORE CG'MCLLTING FORM
Ralph Gonzales ____ ----- 417 ----- Associated Rd., A232, B
City of Carlsbad -- ---.._ 1200 Carlsbad .--. Village Dr., Carlsl
Hertz Claim Management -- P.O. BOX 710400, San Diego,
.*C.€5S .YoLI'.cIf II**L','C€I
COmnCC7 *AM1 08 $Y*LO.Cn bricm(I5s
COtwCCr *&w# OS .sr)~mAU. CAenlan r-15.
1. The injured employee claims thot while employed OS o Utility Systems - Operator 111
3CCL.P.1C" .t ,%-a OF '*,<,W.l
on 1-3-90 & 10-29-91 at Car lsbad CA
:5.'€ os IW,"DIl 1C1-7' 0. .=,
(i)hc sustained injury arising out of and in the courre of employment to -bzkd(rlnkleL
osrart *-AT -4eT3 os SOQI rrc.r ,WM,CO,
2. The parties hereby agree to settle qny aod dl claims on occcrunt of soid injury by thc Foymevt of the sum of f &-%.&%
to any sums hercto'ore pod by )!le employer or the insurer to the .?mployie. 1~5% 0-.:070*~ sf4 forth in Paraqroph No. 6
3. Upon opprovol of this ccrnpromke ggrcerncnt by the Workers' Cornpenrotion Appeals hard or a workers' compensation iu
occordonce with the provrrionr hereof. said crnployce releases and forevw dischrr-jes raid cmployer and insurance carrier
cowses of action, whether rtow known or arcerioined. or which may h -after or'-e or develop 01 a rcrult of soid inpry. it
I.abtlity of soid enrp!op ond sqnd incur.ince carrier ad ench of tticm ts the drpendent3, hem. cxecutori. reprerentatrvc
ossigns ct mid employee.
IJnler% otherwise ?rprri:ly nrorded here.?, opprovol cf thii ogrcemcnt kELSa5ES ANY AND ALL CLAIMS OF APPLICANT
DEAIH 9ESEFITS RELAllNG TO IN,iJRY OR 1NJCRlk.S COVERED RY 'Ills COUPROMI'.E 4G;EEMENI The poriirc
releoic of there bcnetttr in orriving I? the sum In Porograph fh. 2
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5, Unless otherwise exprosly or.?erc?d by a workers' compenrution iudge, opprovui of 1ht\ oylccnlent DOES NOT QELFASC
CANT MAY NOW OR PEREAFTER HAVE FOR RFh AElLlTAliON OR BENEflTS IN CONNECT'ON WITH REr(ABILITATI(?N
6. The parties represent thot the following facts ore true: ,If facts ore disputed, stote what eorh portf con!endr under Parigropt
9-12-56 $543041 & 576.44 -.--------_-___-- 6-18-90 L 12-11-91
OITC oc .1R?* .C?VAL Eb*msW3 a1 ?-a ..IUII lrs~ r~r or8 IQI. QUI 'D .-
--- - - ---- -- - - - --- - -- -- ----- - --.-_ __- -- - -- PAYMENTS MADE BY EMPLOYER OR INSURANCE CARRIER. ------ IEICOIAIV O.¶AOWT. 8WOEMWfT *raeaCv ma71 PtW100J t'J*CYCD
3%. 00. 26600 10/10/93 - 1WI f 1/7/90-6/18/90, 12/9 m
TO1AL YLMAC AN0 rOS*'t.C OIkLI
1056.00,6308.00
13,370.00. EULOO 23.089.05, 4755.05
Cg.Y.r(SI 01SA.ICITV IUMyl*r* - --
BENEFITS CIAlMED BY IN JURED EMPlOYEE
gtww..*W. .No CWrC) 0111) OS ALb 0€l.-S OcI OU& IC) fWS IhiWV uto~a~ **o -C~*I?~L CUI C~O DV tu*Lo*rC
Same as above none known -_-_ 'OfAI u-r.~) YeocaL .wo WOS*.T~C EsCINU €SIIY.rtO Ct -''=E UlPCIL EU.€NSk
Ttn Ik. I'iA P?.: All authorized care has -9id - ___ ------- T+l h* i'.llt\ I;\. Applicant --- --- ---_.-.--._ --._ - ----_- - .-_-_ - 3 -- ---
THE FOLLOWING AMOUNTS ARE TO BE DEDUCTED FROM THE SETTLEMENT AMOUNT: Any and all p€?.rm
advances s 15,290.00 PAYABLE 70 defendant, PDA'S -I - PAY 46LE TO --
s PAYABLE 10 ___-___. 5 --I PSYABLE TO -_____.
I PAYABLE 10 S --P4YAElE 70
EAVING A BALANCE OF $ 19 I 3 3 5 ko, less opprcvcd attorney fee (See Poragroph No. 0; payable to opplicont.
orher thon in o lump sum, or there is additional informotion, specify on separate p03e:~i.) "Advances of 13,370.00 for date of injury 1/3/90 c Advances of 1,920.00 for date of injury 10/29/91
a 0 m
, 7 L,~S yt mentioned in Fordgraph Ne. b ore 19 be dispoled of 01 followr: -&ne ---.
-- -- -- ---- I_
e for che purpose ofdetermining th. 1;- claim(s) Iikd for benefits paid purrwontto the Unemployment lnsurwe Code c
by Iwn clo1rnon)r defined in labor Code kc. 4903.1. the parties propose reductmn 01 the lien claim(s) in accordance wit)
9, Applicant's (employee's) ottomey mpCrt¶ o fee of f Amount of attorney fee previovrfy paid, if ony
0. Rearon for Compromise. special prorid regarding rehabilitution and death benefit c{oimr, and odditionol iniormdon
N/A
Applicant desires to control his cm dical care, and understands this settlem
Hertz Claim I4anag-t and City of Carlsbad from the provision of any further be^ medical treatment.
The applicant desires a lurrp sum settlement and both parties wish to avoid the k
of further litiqation.
Defendant will be entitled to credit for all permrent disability advances paid t
through date of Order Approving the Compromise and Release, unless otherwise spec
Applicant acknowledges that this settlemnt includes, settles and is in consider;
all rights of his dependents-to death benefits which may arise from the injuries
Interest is waived if proceeds of the ComprOmise and Release are paid within twer
of receipt of Order of Approval.
. claimed herein.
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1 I( is agreed by 011 pontes hereto tho* the filing of thtr datumen1 IS he filing cl an oppljcotion on behalf of the r-iplay
moy in ;rr dixrerton ut the mower for heoring os a regulor opplic.mon. reserving to the parties fhr right io put in 'IUJ* 08
herein. and rhd if hearing IS held with this document used ar on oppltcohon the drlendacts sholl hove .woJable to then
arodoble os 01 the dote of filing of this document. ond thoi the WCAB moy thwrofter cdher approe sard Ccmpiornw
or dimpprove the same and issue F;ndings and ArorJ oher heoring hor been held nnd ?lie rnowet reg-Jlorly rubmined fc
- --. I!) 9s- ,(It 2&!5&3-
_I_- Gonzales
Barbara Stokes -HCMm v-e e-ea1.7 irv~o~a E# UCS~*V.~ YV¶* u *Rm¶?eO ar -0 or~rcml¶.lO *am¶O%a OR .C.WII~OUD awow --X.--~.IC
1 1;T;tTE OF C ll.lFORXl.4
(*Otrnty oj San Diego
f ?,I this
1 .Yl,tury PrcMir in old jor rhv aid County nttd Stntc. wding thiwin, rfrtfy ~.~I~II~~II~~II~I!,~(~ t:~t,/ crwrn. p,rvmdIy i~i
dl1 y of .I n , 1.9 __. I*-f4,re rllf'.
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,~tlfia.rtIwJ 141 /he ti ithin !n~trit~nt*nt. und ac.Lnorc.kdpi to r:ic tht .--hi*-- (*XI.~ IJ~I.~! fh,. \<;ifti.
I\' 1t-l ~-.YE.\.s \\'Ijf:H!-( )F. f Ittit t* ht.rt.iivito \t*t nry ltritrtl ,ind rijjtitd riitl ftj'r:, it:/ \a 11) (/:a. rLi, diu/! tp Air in rh t
L nrit4.n to niq In I** th pvwti- ti Irnst. noriic- ---? ..e. ..,