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Home My WebLink About1992-11-10; City Council; Resolution 92-332ll e 0 1 2 3 4 RESOLUTION NO. 9 2 - 33 2 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF CARLSBAD, CALIFORNIA, AUTHORIZING THE EXPENDITURE OF FUNDS FOR SETILEMENT OF THE WORKERS’ COMPENSATION CLAIM OF MARK CHRISTENSEN 5 11 WHEREAS, Mr. Charles Loof, Defense Counsel for the City of Carlsbad in this ‘ Latter, has recommended a settlement of the Workers’ Compensation claim of Mark 7. 8 9 10 I1 12 Zarlsbad, California, as follows: 13 1. That the above recitations are true and correct. 14 2. That the expenditure of $22,000 from the Workers’ Compensation Self- Christensen; and WHEREAS, there are sufficient funds available in the Workers’ Compensation Self- ksurance Fund to pay the settlement, NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of 15 Insurance Fund is authorized for the settlement of said claim. 16 3. That the Council accept the Compromise and Release, attached hereto as I? 1 18 19 1 , 20 21 22 I 23 I I j I I 24 ! 25 j 27 I 26 I 28 I Exhibit 2. W W PASSED, APPROVED AND ADOPTED at a Regular Meeting of the City 1 2 3 vote, to wit: Council of the City of Carlsbad on the 10th day of NOVEMBER 1992, by the following 4 AYES: Council Members Lewis, Kulchin, Larson, Stanton, Nygaard 5 NOES; None 6 ABSENT None 10 :, 11 TTEST: :ph& J. ;Ps?/y ETHA L. RAUTENKRANZ, City Clerk 14 15 16 17 18 19 I 20 21 22 23 24 25 26 27 28 7 0. -. L.-.,,IU.L L ' ,+ ."-f ,COMPRO~SE AND RELEASE STATE OF CALIFORNIA @TI 4 MPARTMENT OF INDUSTRIAL RELATIONS. . -~ :A '4 U PLWE SEE INSlRUCTlONS ON REVERSE OF PAGE 2 BEFORE COMPLETING FORM DIVISION OF WORKERS COMPENSATION CASE NO.- SOCW SECURrrY NO. 537-76- WORKERS COMPENSATlON APPEALS BOARD P.O. Box 1423 Mark Christensen Enumclaw, WA 98022 City of Carlsbad, P.S.I. Carlsbad, CA 92008 APPLICANT [EMPLOYEE) 1200 Carlsbad Village Drive 3954 Murphy Canyonv&2d, Suite *DORESS CORRECT WE OF EMPLOYER HCM Claim Manaaement San Diego, CA 92123 CORRECT NAME OF INSURANCE CARRIER MORES 1. The injured employee claims that while employed as a Police Officer LOCCUPATIONATTIVE OF INJURY) on 9/28/91 at Carlsbad Califoaa , by tt $)he sustained injury arising out of and in the course of employment to @ 2 The parties hereby agree to settle any and all claims on account of said injury by the payment of the sum of$ 22 r 000 01 in addition to any sums heretofore paid by the employer or the insurer to the employee, less amounts set forth in Paragraph No 3. Upon approval of this compromise agreement by the Workers' Compensation Appeals Board or a workers' compensation judge a in accordance with the provisions hereof, said employee releases and forever discharges said employer and insurance car claims and causes of action, whether now known or ascertained, or which may hereafter arise or develop as a result of including any and all liability of said employer and said insurance carrier and each of them to the dependents, heirs, representatives, administrators or assigns of said employee. (OATE OF INJURY) tClM A (STATE WHAT PARTS CF 9OOY WRE INJURED) 4. Unless otherwise expressly provided herein, approval of this agreement RELEASES ANY AND ALL CLAIMS OF APPLICANT'S DER DEATH BENEFITS RELATING TO INJURY OR INJURIES COVERED BY THIS COMPROMISE AGREEMENT. The parties have cons 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 CI 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 under Para MTE OF BIRTH ACTUALEARNlNGSATTlME OF INJURY WMYOFFWORKDUETOTHISINJUI 4/20/62 $801,64/weeklv 9/30/91 and cont- PAYMENTS MADE BY EMPLOYER OR INSURANCE CARRIER .. TEMPORARY DISABILITY INDEMNIlY WEEKLY RATE PERIODS COMRED Fully compensated under Labor Code Section 4850 PERMANENT DISABILITY INDEMNITY TOTALYFDIW-AN0 HOSPITAL W.LS None $10,800.02 BEGINNING AND ENDING DATES OF ALL PERIODS OFF DUE TO THIS INJURY Ful ly MEDICAL AN0 HOSPITAL BILLS PAlO BY EMPLOYEE compensated under Labor Code Section 4850 None To BE PAID BY:Previously authorized by defendant TO BE PAID BY: Applicant THE FOLLOWING AMOUNTS ARE TO BE DEDUCTED FROM THE SEllLEMENT AMOUM: BENEFITS CLAIMED BY INJURED EMPLOYEE TOTALUNPAlOMEOlCALANOHOSPlTALMPENSE Applicant, except as ESnYATED FUNRE MEDICAL EXPENSE $Zero PAYABLE TO s PAYABLE TO s PAYABLE TO s PAYABLE TO $ PAYABLE TO d PAYABLE TO LEAWNG A BAiANCE OF $ 2 2 I 0 0 0 - 00 , less approved attorney fee (See Paragraph NO. 9). payable to applicant. (If pay1 be other than in a lump sum. or there is,additiqnal,information, specify on separate page(s) . ) Less any permanent dlsablllty advances pald to applicant from the date of preparation of this Compromise and Release to the date of payment of the Order Approving Compromise and Release. 905 DIA WCAB FORM 15 (REV. ZXlOl (PACE 11 15 '# 0 e- l 7. Liens not mentioned in Paragraph No. 6 , to be disposed of as follow: P' 8. For the purpose of determining the lien claim(s) filed for benefits paid pursuant to the Unemployment Insurance Code Or fa furnished by lien claimants defined in Labor Code Sec. 4903.1, the parties propose reduction of the lien claim(s) in accord' formulae attached. Not appllcable 9. Applicant's (employee's) attorney requests a fee of$ 26 ?'- c '' . Amount of attorney fee previously paid, if any, S 3 10. Reason for Compromise, special provisions regarding rehabilitation and death benefit claims, and additional information: See attached page 2-A 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, a1 WCAB may in its discretion set the matter for hearing as a regular application. reserving to the parties the right to put in is the facts admitted herein. and that if hearing is held with this document used as an application the defendants shall have a them all defenses that were available as of the date of filing of this document, and that the WCAB may thereafter either ap Compromise Agreement and Release or disapprove the same and issue Findings and Award after hearing has been held and regularly submitted for decision. Witness the signature hereof this day of , 19-1. at Er WITNESS APPLICAN~EUPLOYEE) Mark Christensen WITNESS THE APPLICANrS (EMPLOYEES) SIGNATURE MUST BE AllESlED BY TWO DISINTERESTED persons OR ACKNOWLEDGED BEFORE A NOTARY PUBLIC. Charles J. Loof, Esq. for Def enda STATE OF- WASdrdhTod I Countyof t Lor; Rab\nsao, on mis j 3 - day of f)&" 49 AD.. 79 43 , beforeme, m"d. &wy+3R& W a Notary Public in and for the said County and Sate, rysiding therein, d& commissioned and Sm3rn. personally appeared mac K r (St eflsen "\"= t I\ knom,tometobetheperson_ +:+e 8 j. do\/ P subscribed to the within hstrument~-~ ' pat-b- execuled the Same. c' v _-cpi* IN WlTNESS WHEREOF, I haw tu?r&nf&e~~~~ my official Seal the day and year in this CerMicate first abOw written. 5 5 "+a- 5 s 95, p118L\C s -8 2% 5 -57 "q 79 -96.*-<QA.."- ="22 DIA WWB FORM 15 [REV. 2/90) [PAGE 2) 'tt* 1. OF 18\\\%\%*" , , , . -, \\?&% -2. Notar>lPuWic in and tor said c? countyamstate " of California 4 ,i J e '. F APPL1CANT:Mark Christensen COMPROMISE AND RELEASE CASE NO. : =A) This settlement includes any and all claims for medical temporarydisability, vocational rehabilitationtemporary disability and reimbursements through the Order Approving Compromise and Release. -!-e Initia s XB) It is further understood and agreed that the aforesaid sum includes interest as provided by law for a period of twenty-five (25) days from the date of service by the Workers' Compensation Appeals Boar& ,ge Order Approving Compromise and Release, Initia - xx C) DEATH BENEFIT CLAIM WAIVER: The applicant has been advised and fully understands that this Compromise and Release Agreement releases any and all claims of any dependents to potential death benefits relating to the injury or injurie cov red by this Compromise and Release Agreement. Tkigk", - XX D) A reasonable and substantial dispute exists between the parties as to: Nature and extent of the applicant's disability, both temporary and permanent; need for past, present, and future medical treatment; reimbursement for self-procured expenses; etc. Rather than risk the uncertainties of litigation, the s wish to settle this claim, and all its res d potential issues, via a lump sum certain. nyg"-j= Init1 =E) RODGERS SETTLEMENT: [Rodaers vs. WCAB (1985)-, 49 Cal. Comp. Cases 5611 As part of the consideration for this Compromise and Release, applicant forever releases the defendant from any liability arising out of future injuries that might occur during vocational rehabilitation and compensable consequence of the original injury. p, 7 Initials DATE: 10 -9 -9 2. APPLICANT : I - DATE : / 2 -A