HomeMy WebLinkAbout1995-05-16; City Council; 13143; SETTLEMENT OF WORKERS' COMPENSATION CLAIMS OF CHRIS KOWALSKIs 9-
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Cla OF CARLSBAD - AGENU BILL i c5
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DEPT AB# j?. lLf2 TITLE:
MTG. 5/16/95 COMPENSATION CLAIMS OF CHRIS CITY SEmEMENT OF WORKERS’
DEPT. RM KOWALSKI CITY
RECOMMENDED ACTION:
Adopt Resolution No.
payment of $15,000 to Chris Kowalski.
q5- j@ approving the Compromise and Release which authorizes thc
ITEM EXPLANATION
The claimant is a former Police Officer in the Carlsbad Police Department. He was
employed by the City for a period of 6 years prior to his retirement on November 1, 1994.
Mr. Kowalski was injured on July 22, 1993 while involved in the pursuit of a suspect. He w
reaching to apprehend the suspect when he tripped and fell, injuring his left shoulder and
both knees.
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 the attorney
representing the claimant and the attorney representing the City, and have been approved
HCM Claim Management, the City’s Third Party Administrator.
FISCAL IMPACT
The total cost of the settlement is $15,000. There are sufficient funds available in the
Workers’ Compensation Self-Insurance Fund to cover the cost of this settlement.
EXHIBITS
1. Resolution No. %-U6
2. Compromise & Release
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RESOLUTIONNO. 95-126
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 CHRIS KOWALSKI
WHEREAS, Mr. Gary Bourassa, Defense Counsel for the City of Carlsbad in tt
matter, has recommended a settlement of the Workers Compensation claims of Chris
Kowalski; and
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:
1.
2.
That the above recitations are true and correct.
That the expenditure of $15,000 from the Workers Compensation Self-
Insurance Fund is authorized for the settlement of said claims.
That the Council accepts the Compromise and Release, attached heretc
Exhibit 2.
3.
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PASSED, APPROVED AND ADOPTED at a Regular Meeting of the C
Council of the City of Carlsbad on the 16th day of MAY 1995, by the following
vote, to wit:
Am:
NOES: None
ABSENT: None
Council Members Lewis, Nygaard, Kulchin, Finnila, H
Amr:
&&e* Z, City Clerk
KAREN R. KUNDTZ, Assistant City Clerk
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0 EXHIBIT 2
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF WORKERS' COMPENSATION
WORKERS' COMPENSATION APPEALS BOARD
CASENO. SDo '
SOCIAL SECURITY NO. 31f-l
0 COMPROMISE AND RELEASE
PLEASE SEE INSTRUCTIONS ON - REVERSE OF PAGE 2 BEFORE
COMPLETING FORM
1050 HAZEN DRIVE
12 00 CARLSBAD VILL%%sSDRIVE CARLSBAD, CA 92008
P.O. BOX 710400 SAN DIEGO, CA 92171
CHRIS KOWALSKI SAN MARCOS, CA 92069
CITY OF CARLSBAD
HERTZ CLAIMS MANAGEMENT
1 The injured employee claims that while employed as a
on 7/22/93 at CARLSBAD CA
(s)he sustained injury arising out of and in the course of employment to Rt. thumb, both knees, both lower extremities,-
APPLICANT (EMPLOYEE)
AD OR ESS CORRECT NAME OF EMPLOYER
ADDRESS CORRECT NAME OF INSURANCE CARRIER
POLICE OFFICER
(OCCUPATION ATTIME OF INJURY)
(STATE] - (DATE OF INJURY) (CITY1
Lt - Shoulder, Lt- Upper Extrem
2 TIhe p ment of the sum of $ .-
in addition to any sums heretofore paid by the employer or the insurer to the employee, less amounts set forth in Parag
3 Upon approval of this compromise agreement by the Workers' Compensation Appeals Board or a workers' compensation
in accordance with the provisions hereof, said employee releases and forever discharges said employer and insurar
claims and causes of action, whether now known or ascertained, or which may hereafter arise or develop as a re!
including any and all liability of said employer and said insurance carrier and each of them to the dependents,
representatives, administrators or assigns of said employee
4 Unless otherwise expressly provided herein, approval of this agreement RELEASES ANY AND ALL CLAIMS OF APPLlCAN
DEATH BENEFITS RELATING TO INJURY OR INJURIES COVERED BY THIS COMPROMISE AGREEMENT The parties hav
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 RELEAS
CANT MAY NOW OR HEREAFTER HAVE FOR REHABILITATION 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 un
TE WHAT PARTS OF BODY WERE INJURE .&, &g?/
ACTUALEARNINGSATTIME OF INJURY LAST DAY OFF WORK DUE TC DATE OF BIRTH 7/15/61 $836.37 PER WEEK IN DISPUTE
PAYMENTS MADE BY EMPLOYER OR INSURANCE CARRIER
TEMPORARY OlSABlLlN INDEMNIM WEEKLY RATE PERIODS COVERED
ALL PERIODS ADEOWTnY ComEn
PERMANENT DISABILITY INDEMNITY TOTAL MEDICAL AND HOSPITAL BILLS
$3,080.00 - FD ADVANCES
BENEFITS CLAIMED BY INJURED EMPLOYEE
BEGINNING AND ENDING DATES OF ALL PERIODS OFF OUE TO THIS INJURY MEDICAL AN0 HOSPITAL BILLS PAID BY EMPLO'r
IN DISPUTE UNKNOWN
TOTAL UNPAID MEDICAL AND HOSPITALEXPENSE ALL BY APPLICANT, NONE ESTIMATED FUTURE MEOICAL EXPENSE ALL
ToBePaidBy BY DEFENDANT EXCEPT PER PARAGRAPH 7 ToBePaidBv NONE BY DEFEl
THE FOLLOWING AMOUNTS ARE TO BE DEDUCTED FROM THE SETTLEMENT AMOUNT
PAYABLE TO $ 3 r O8 o o o PAYABLE TO PD ADVANCES $
$ PAYABLE TO $ PAYABLE TO
$ PAYABLE TO $ PAYABLE TO
LEAVING A BALANCE OF $ 11 r 9 20 0 0 , less approved attorney fee (See Paragraph No g), payable to applice
be other than in a lump sum, or there is additional Information, specify on separate page(s) 1 LESS ANY FURTHER PERMANENT DISABILITY ADVANCES TO THE DATE OF THE 0
DWC WCAB FORM 15 (REV 1992) (PAGE 1)
0 0
7. Liens not mentioned in Paragraph NO. 6 are to be disposed of as follows:
8. For the purpose of determining the lien claim(S1 filed for beneflts paid pursuant to the Unemployment Insurance Co
furnished by lien claimants defined in Labor code Sec. 4903.1, the parties propose reduction of the lien claim(s) in
formulae attached.
9. Applicant's (employee's) attorney requests a fee of $ i x()(]- . Amount of attorney fee previously paid, if an
10. Reason for Compromise, Special provisions regarding rehabilitation and death benefit claims, and additional informatio
SEE ATTACHED EXHIBIT "A"
INCORPORATED BY REFERENCE
11. It is agreed by all parties hereto that the filing of this document IS the filing of an.application on behalf of the empl
WCAB may in its discretion set the matter for hearing as a regular application, reserving to the parties the right to [
the facts admitted herein, and that if hearing is held with this document used as an application the defendants shal
them all defenses that were available as of the date of filing of this document, and that the WCAB may thereafter e
Compromise Agreement and Release or disapprove the same and issue Findings and Award after hearing has been h
regularly submitted for decision.
Witness the signature hereof this 1'4% dayof hi? 1r-j ' ]
WITNESS
SCOTT O'MARA, &J!C Y. FOR APPl WITNESS
THE APPLICANT'S (EMPLOYEES) SIGNATURE MUST BE Al7ESTEO BY TWO DISINTERESTEC
PERSONS OR ACKNOWLEDGED BEFORE A NOTARY PUBLIC.
JOSEPH W. RIPPINGER, I11
ATTORNEY FOR DEFENDANT
J
\
r STATE OF CALIFORNIA
County of h j '&C% a
on this 1 9% day of bf\\ AD., 79 qs, beforeme, CUQ Ciczycru
a Notary Public in and for the said County and State, residing therein, duly commissioned and sworn, personally appeared-
CI?.r<S kC;L.;c,\Ski
known to me to be the person 4 whose name
subscribed to the within lnstrument, and acknowledged to me that-he- executed th& same.
IN WlTNES WHEREOF, l have hereunto set my hand and affixed my official seal the day and year in this Certificate first abo\
written.
QP?~Q~ S 0~ Con P f a~\ sc % & \ eq :>f
Td
OWC WCAB FORM 15 [REV. 1992) Notary PublrC In and for sard Countyandstate of Calltornla
e e
RE: CHRIS KOWALSKI vs. CITY OF CARLSBAD
WCAB NO.: SDO 0194593
ADD END UM 11 A 11
A dispute exists between the parties as to -, m M-’, liability for self-procured and future mec , w, periods of tempc treatment, huuI,’*-? w
disability, permanent disability ?nd - The par wish to avoid the hazards and uncertainties of
and settle by the lump sum contemplated herein.
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The settlement includes any claim for interest up to twenty-
(25) days of the service of Order Approving Compromise and Re1 upon defendants.
Applicant has been advised and fully understands that
Compromise and Release agreement releases any and all claims ol
dependents to death benefits relating to the injury or injL
covered by this compromise agreement.
The applicant has been advised and fully understands that
Compromise and Release Agreement releases any claim of in:
either specific or cumulative, resulting from past or fL rehabilitation process which emanated from the injuries referrt on page one, paragraph one of this agreement. This paragraph not contemplate settling other normal vocational rehabilitz benefits in the future as a result of the injury herein. Roc
vs. WCAB 50 CCC 299 (1985). Carter vs. County of Los Anqe (Weatherspoon) vs. St. Ferdinand’s School and Constancio vs.
An elas C:-”nty, 51 C.C.C. 255 (i986) and any srrbsequent nodif
ZUd- CHRIS KOWALSKI, APPLICANT DATED:
y-/c/-75 f
DATED: