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Bob Ferguson

ATTORNEY GENERAL OF WASHINGTON
Torts Division
800 Fifth Avenue • Suite 2000 • MS TB-14 • Seattle, WA 98104-3188 • (206)464-7352

MEMORANDUM
DATE:

July 23, 2014

TO:

Department of Enterprise Services
Office of Risk Management
P.O. Box 41466
RiskLitigationdes.wa. gov

FROM:

Susan Edison, Assistant Attorney General
Tort Claims Division

SUBJECT:

Claim of Baily Stober (OMWBE)
ORM FILE NO. 14770004

Enclosed please find the following documents:

]

Certificate of Tort Claim Settlement (original)
Settlement Agreement and Release (copy)

These documents are forwarded to you to be processed for payment per instructions on the
Certificate, as permitted under RCW 4.92.
Insurance available or paid by or on behalf of State: YES
Amount:
Insurer:
Insured:

$

Thank you.
SE/jkd
Attachments
cc wI attachments:
Charlynn Hull (via email)
Gina Comeau (via email)
Teri Metcalf (via email)

•

NO

 ORM FILE NO. 14770004

CERTIFICATE OF TORT CLAIM SETTLEMENT
(For payments where a suit has not been filed)
Bailey Stober Claim (OMWBE)

TO THE RISK MANAGER OF THE DEPARTMENT OF ENTERPRISE SERVICES,
OFFICE OF RISK MANAGEMENT:
Lucy Isaki of the Department of Enterprise Services as designee for the Office of Minority
and Women Business Enterprises certifies as follows:
A claim based on the claimed tortious conduct of the State of Washington has been settled
and should be paid from the Liability Self Insurance Fund pursuant to RCW 492.160.
For payments made as a result of Bodily Injury: N/A
Claimant Full Name:
Claimant SSN:
Claimant HICN:
Claimant Date of Birth:
Claimant Gender:
Law Finn Tax lDNo:
Attorney SSN:

OR

(Risk Management must have the Social Security number and Medicare Health Insurance
Claim Number for each claimant and will report the entire amount for Medicare
Secondary Payor purposes unless the distribution amount, including the attorney 's
payment, has been confirmed in writing by claimant's attorney. Office of Risk
Management must also have the Tax Identification Number for the law firm or Social
Security number for the attoiney.)
S

Date Claim Filed:

February 20, 2014

Occurrence Date:

Approximately November 1, 2013 until February 28, 2014

Location:

Washington State Office of Minority & Woments Business Enterprises
(OMWBE),

Total Settlement Amount:
Payable to:

$125,000M0

The Trust Account for HKM Employment Attorneys LLP for the benefit of
claimant Bailey Stober

 Send Payment to: LISA A. BURKE
HKM Employment Attorneys LLP
Puget Sound Plaza
1325 Fourth Avenue, Suite 540
Seattle, WA 98101
Amount to Be Paid to Annuity Company, If Applicable

N/A

1099-MISC REPORTING
A.

Is payment ($600 or more) to be issued as a result of a
NON-PHYSICAL INJURY?
YES
NO
If "Yes" a 1 099-MISC is to be reported against the claimant in the entire
amount even if the payment is made directly to the claimant and their attorney.
The Office of Risk Management will only split 1099 reporting between the
claimant and an attorney when the amount of the distribution has been
confirmed by claimant's attorney. Payments made for the purchase of annuities
do not require 1099 reporting.
,

Non-Physical Payment Made to Claimant: (Entire amount ofpayment must be
made to claimant unless there is a split with the attorney as described above)

Amount to Claimant:
Claimant (payee) Name
Last Kno wn Address

City/State/Zip:
Social Security Number:

$125,000
The Trust Account for 11KM Employment
Attorneys LLP for the benefit of claimant
Bailey Stober
do LISA A. BURKE,
HKM Employment Attorneys LLP
Puget Sound Plaza
1325 Fourth Avenue, Suite 540
Seattle, WA 98101

Non-Physical Share of Payme1L Maae to Attorney; (unly to be made when
claimant's attorney has confirmed the dollar split between the parties.)

Amount to Attorney:
Attorney Name:
Address:
City/State/Zip:
Social Security or
Tax I.D. Number:

2

 B.

Is payment ($600 or more) issued directly to an attorney for
PHYSICAL INJURIES?
YES [I]
NO
If "Yes" the entire payment is to be reported against the attorney. Physical
,

Injury payments made to other parties, to include the claimant, do not require
1099 reporting. Payments made for the purchase of annuities, do not require
1099 reporting.

Physical Injury Payment Made Directly to Attorney:
Amount to Attorney:
Attorney Name:
Address:
City/State/Zip:
Social Security or
Tax I.D. Number:
DATED this

day of July, 2014.

Approved by:

Approved by:

LUCYISAKI
State Risk Manager

ROBERT W. FERGUSON
Attorney General

Department of Enterprise Services
Office of Risk Management

SSAN EDISON, WSBA#1 8293
Assistant Attorney General

SE/jkd
Enclosure

3

 SETTLEMENT AGREEMENT
AND RELEASE OF CLAIM
Tort Claim of Bailey Stober (Washington State Office of Minority &
Women's Business Enterprises (OMWBE))
FOR AND IN CONSIDERATION of the sum of One Hundred Twenty Five Thousand and
00/100 DOLLARS ($125,000.00), Bailey Stober, his heirs, assigns, community, family, and other
successors in interest (hereinafter, "claimant"), do hereby release and forever discharge State of
Washington and the Washington State Office of Minority & Women's Business Enterprises
(OMWBE) and its officers, agents, employees, agencies and departments, (hereinafter,
"Defendant"), from any and all existing claims, damages and causes of action arising out of
Stober's employment at OMWBE (hereinafter, "Subject Incident") from approximately November
1, 2013 until February 28, 2014, including but not limited to all claims for personal injuries to
Bailey Stober in the tort claim for damages filed by the claimant with the Office of Risk
Management of the STATE OF WASHINGTON on February 20, 2014 as ORM # 14770004.
This release is intended to settle and compromise all actual, alleged, and potential claims, damages
or causes of action which arise from or relate to the subject incident, and specifically contemplates
the following non-exclusive damage issues that exist as of the date of this release: past and future
pain and suffering, past wage loss, and any future wage loss related to the subject injury of this tort
claim.
FURTHER, the undersigned claimant represents warrants and agrees that:

1. This is a final, conclusive and complete release of all unknown and unanticipated
damages arising out of the above-stated accident, occurrence/ event as well as those now known,
disclosed or anticipated..
2.
The undersigned claimant will indemnify and save harmless the parties herein
released from all loss, damage and expense incurred directly or indirectly by reason of the falsity or
inaccuracy of any future representation by the undersigned claimant with respect to the terms and
conditions of this settlement.
3.
This settlement agreement and release does not constitute any admission of fault
or liability on the part of the parties released herein; nor should it be construed as recognition
of claimant's theories of liability, which are disputed.
4. As the provider of human resource services for OMWBE, Terry Wilson, the HR
Director at the Department of Enterprise Services (or current incumbent), will provide employment
references for Baily Stober. The references will include a letter thanking Bailey Stober for his
service to OMWBE with the dates of his service and job titles and a verbal reference that includes
Bailey Stober's dates of his service and job titles.
Bailey Stober and the attorneys for the parties agree that they will not initiate contact
with the media regarding this settlement. Additionally, if the media contacts the claimant or his
representatives, they (claimant or his representatives) will contact the assigned Assistant Attorney
General, Susan Edison, regarding the media's interest. If any statement is made, it is to be a joint
statement by both parties.
.

6.

The State of Washington agrees to pay the entire cost of mediation in this matter.
SETTLEMENT AGREEMENT AND RELEASE
Bailey Stoberl ORM# 14770004
Page 1 of 3

 7. The settlement amount of One Hundred Twenty Five Thousand and 00/100
DOLLARS ($125,000.00) is not considered to be lost wages because Bailey Stober left
OMWBE for a position at DSHS.
8. The following payment will be made in full and final settlement of all claims arising
out of the subject incident in the total settlement amount of One Hundred Twenty Five Thousand
and 00/100 DOLLARS ($125,000.00). This settlement includes any attorney fees, costs and any
adverse tax consequences.
9.
Pursuant to the provisions of RCW 4.92.160 the defendant shall issue the following State
warrant (check) made payable to: The Trust Account for HKM Employment Attorneys LLP for the
benefit of claimant Bailey Stober and in the amount of One Hundred Twenty Five Thousand and
00/100 DOLLARS ($125,000.00)
10. The undersigned claimant hereby declares that the terms of this settlement have been
completely read and are fully understood and voluntarily accepted, for the purpose of making full
and final compromise, adjustment and settlement of any and all claims disputed or otherwise
(except as alternatively provided herein) relative to the subject incident.
11. This release contains the entire agreement of the parties, but it shall not be
binding upon the State until approved and accepted by a duly authorized representative of the
State in accordance with RCW 4.92.160.
DATED this

/('çP

day of

STATE OF WASHINGTON)
•
)ss.
COUNTY OF______ )
I, .?Jr/oja.. JT). [bZY I
the undersigned a notary public in and for the
State of Washington, hereby certify that on this
day of
//personally
appeared before me, BAILEY STOBER, to me known to be theifidiviEIual described in and who
executed the foregoing instrument, and acknowledged that he signed and sealed the same as a free
and voluntary act and deed, for the uses and purposes therein mentioned.
Given under my hand and official seal the day and year last written.

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'PUBOC

V)Y28tC

ame printed
Notary Public in and for the
State of Washington
My Commission Expires: Olc \ LZ\ O1y

111;4111 IM0

SETTLEMENT AGREEMENT AND RELEASE
Bailey Stober / ORM # 14770004
Page 2 of

 By signature below, claimant's attorney acknowledges that the Office of Women and
Minority Business Enterprises (OMWBE") has no payment or other obligations to claimant's
attorney or HKM Employment Attorneys' LLP, and that upon OMWBE making the payment
specified in the foregoing agreement, OMWBE will be released from any and all attorney fee
liens in connection with the settlement.
DATED this /

day of

2014.

LISA A. BURKE
I{KM Employment Attorneys LLP
Claimant's Attorney

APPROVED and ACCEPTED

APPROVED and ACCEPTED:

DEPARTMENT OF ENTERPRISE
MANAGEMENT

ATTORNEY GENERAL OF WASHINGTON

LUCY ISAKI
STATE RISK MANAGER

SUSAN EDISON
ASSISTANT ATTORNEY GENERAL

SETTLEMENT AGREEMENT AND RELEASE
Bailey Stober / ORM # 14770004
Page 3 of 3