FORM 'cs-339-A COURTOF EXISTINGCLAIMS i 

armamiaiWamiswm sweetie an 1915 NORTH sTlLEs 
in in mind lp-eareggeiapari i OKLAHOMA CITY. OK 73105-4918

 

  
 
  

cuinani 5 mt rim. ilniuma z-aiayeti
BRAD MCGAHEY

initial EM- a span 

Zfitiflsfisn RDER FILED
"52% MAR 1 2014 i
COURT 0.:

  

 

 
   

Men- anemia
ALCOHOLICS AND ADDICTS RECOVERV

mun" cane . hr Coal team ireineiu surname at can an era;

 

     

UNION 8t FIRE COMPANY Any peraen who commits workers'
XISTING CLAIMS

COMPROMISE Section WC Code

This agreement is prepared .Irld submitted pursuant to Section new 0! the Workeia' compensation Code, Title as or the Oklahoma Statutes,
By signing belaw, each party minns that they have read and understand its provisions, declares undo! penalty oi porlury that all statements are
inte and accurate to the best of "Mr knowledge and belief. and understands that the agreement, it approved by m- work-N 
Conn, is conclusive, final and on all the parties involved.

ayt agreement, the Danie! settle upon and dourmine (chock onet:

   

 

is 155 AND IN THE CLAIM sows, an 301' ALL, ISSUES an MATTERS THE CLAI Aluch appendix
iseilaiient and wiih Full Release) otall cuisianding issues the appendix is tubiaei approval by the Workm' 
was" tnii .u "a iaiit' i, imi i mi ail ,ai trim" estin it MUST accompany the Penn cs 31%, and be dated anti Signed by ull panics under
we at Wat i. . .ai. a are can i, am>> penalty pipenury
lt is hereby agreed by and between the above named parties that the daimant alieges to have sustained a wmperrsable accidental in,ury on or
aoout 5/27/19 imlle in the employ eittie employer causing me tellcwing iniury (describe nature oriniury) ten hand/wrist and any other body parts known
or unknown tend resulting in temporary total olsa irom to or lei a pence el_ weeks 7 days tor which the claimant received
PAID lN l. in compensation item the employerfinsumnce earner. The manrs ayerage weekly wage is late the iniury entlues the claimant la a
compensation rate at: lea as lor Temporary Tetal Disability and 19?g? tor Permanent Pamal DIsahllify/Pemlarlem Panlal lmpa'inrienl

2 A claim ler campehsatien was filed by the claimant tor the inpiry' an it the claimant is not represented by an attorney an Employers First Notice bi lrliury
iFonn 2t ms by the employer tor the lVIJUfyi and the Wumars' Compensation court has itihsdiction in this matter:

3 This is an agreement in mich the claimant agrees |o accept 511 who in full and final setltement at all aaims leg hand/wrist and any other body parts

or unknuwrl sustained as a result uf the accident relenee to ahuve, including any claim by the claimant lor past, present and ltieire
wmnensatlon let temporary teal tempomry partial disability permanent partial impairment or permanent tplal dlsapility, statutory medical treatment,
physical and vocatlarlal rehabilitatien benefits. or loss at wage eaniing capacity, as a result at any and all injuries sustained in the accident This sum is in
addition to any preyibus ameuntist paid to the claimant. and any tor authenzed. reasonabie and necessary medical and rehabilitative expenses
previously incurred by the claimant due to the iniury or said sum 5 ll imam shall be paid tor oennanent partial disability/permanent partial impairment

and$n shall be paidiprsonue

4 For Social Security onset purposes, and it applicable, the claimant agrees in acceptanoihe empicyer/cameregrees to pays lump sum or: a fur
months Therefore, evenmoughpaidma
lump sum dalmarll's benefit (sitar deduction or edmney fees and expenws) shall be considered to be 3 a a month (or months
beginning

shall be deducted hem this settlement and paid to the daiment's alwmay pursuant to the workers' compensation laws oilhe
state

a. The enpgyer/amer agees in pay all applme Com costs. and all axes and to the okiatuna Tax t'mimism, as $140.00 in the Wotkats'
surnpeisaban Court taxed as costs in this mattori unless previously pald' the Special Occupational Health and Saferepresenting mreeJoul'lhs or one percent oi the compmmisa settlement amount, ext-Juding medical payments and temperary total ability
compensation, il a court Anpmved OWN RISK employer or graup sell-insurance association, the Womeis' Compensation Administration Fund Tax in the
sum at 5 gr representing 2% ol the settlement amount, and. it applicable by law, the appropriate Self-Insured Guaranty Fund Tax in the sum

 

 

 

 

 

 

 

 
 
 

 

     
   

 

of - i represemlng 1'7- 0! the settlement autumn and' in addtiian In Dmef amounts, l' a Mulliple lrllury Trusl Fund assessment
ln me slim L79 5 0 representing 5% EllK me campromlse settlement amount
BRAD MCGAHEV 0 Fa p42,"! AND ADDICTS RECOVERY
EWLOVER pain
JENNIFER A. SLOAN 19346
WW, "mass 3/13/14 mute; 4 can

ears ,1 4
CRAIG DAWKINS 2231 3/13
Nutter pea 
3/13/14
pare

 

 

ORDER APPROVING COMPROMISE SETTLEMENT (FORM c543>>): The Woners Campensalim Calumhavlng ieued the eyieenca Vllesand records in
this matter are belng iuily adylsee in in: the above campiernrse Setteniem. incluoiru; attorney tees and the attached anpendlx In ine campiemis. Samemenl, it

issues an: matters in in. nan. ins tats. snaii se niiyane and and its Cabin mien therein
DONE this 13; day elMeich, 2014 15274303 
ay artisan or

a. Amwmluwwumy-uwwmehmhw 
JUDGE on W.
AGI