DIY Legal Forms

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Release Of Claim For Personal Injuries By Employee

(Type B)


[Name and address of employee], hereafter referred to as Releasor, executes this Release on [date].

1. Party Released. This Release is in favor of [name and address of employer], hereafter referred to as Releasee.

2. Employment History. Releasor has been employed by Releasee for [number] years. Releasor's employment began on [date].

3. Wages. Releasor earns the sum of ---------- dollars ($----------) per week.

4. Job Description. Releasor's duties are: [description of position and duties].

5. Injury. Releasor suffered the following injuries while employed by Releasee: [list and description of work-related injuries]. These injuries have been determined by [name and address of doctor] to be permanent [or, temporary].

6. Consideration. The consideration for this Release is ---------- dollars ($----------) receipt of which is acknowledged by Releasor.

7. Subject Matter of Release. Releasor releases Releasee from all claims and causes of action for all known or unknown injuries, physical or mental. This Release binds Releasor's heirs, administrators, executors, and assigns.

8. Medical Expenses. Releasor hereby also releases Releasee from any medical or other expenses incurred or to be incurred as the result of the above-described injuries.

9. Workers' Compensation. This Release fully settles all of Releasor's claims against Releasee pursuant to the Workers' Compensation Law of [state] in regard to the above-described injuries.

10. Neither party has made any representations nor promises, other than those contained in this release or in some further writing signed by the party making the representation or promise.

11. Understandings. Releasor has read and fully understands the terms of this Release. Releasor further states that Releasor has executed this Release of Releasor's own free will.

12. Approval. This Release will not become effective until it has been approved by [state] Workers Compensation Appeals Board.

IN WITNESS WHEREOF, Releasor has set Releasor's hand this [date].



Approval of Board




STATE OF -------)

) ss: [date]

COUNTY OF ------)

On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal.


[Name of Notary Public]

My commission expires: [date]