HomeMy WebLinkAboutSIMONSON, KEITH MICHAEL (2) OCT 3 1 ZQ24 N-2024-320-01
0• Lko(gs WORKER'S COMPENSATION DAMAGE
Jo b \-efV4 -1-)^"'3- RELEASE IN FULL SETTLEMENT AND COMPROMISE
Claim No.: 22-8740152
Cross-Complainant: City of Santa Ana
Whereas we claim to have sustained damage and consequential damage to our employees by reason of an occurrence
happening on or about November 4, 2022 , near the intersection of Bristol and Fifth Street, in the city of Santa Ana,
County of Orange, State of California. Whereas we claim that KEITH MICHAEL SIMONSON and all others legally
responsible for his acts and omissions, if any (hereinafter called Releasees) are legally liable therefore. Whereas
Releasees deny said liability.
Whereas the nature, extent and results of the worker's compensation damages sustained by us are not now all known or
unanticipated, but we nevertheless desire to settle and compromise said claim(s) in full.
Therefore, in consideration of the payment to be received to us of ONE THOUSAND And 871100 Dollars And 84/100
Cents ($1,087.84), of which we acknowledge receipt and sufficiency, WE HEREBY RELEASE, DISCHARGE AND
ACKNOWLEDGE AS FULLY PAID AND COMPROMISED, ALL CLAIMS, DEMANDS AND CAUSES OF ACTION for
reimbursement of the workers' compensation benefits paid to Eric Burkey by the City of Santa Ana, which we may now
have or may hereafter have against the Releasees, their legal representatives or successors, to recover for the
worker's compensation benefits paid by the City of Santa Ana to employee Eric Burkey, and including
consequential damage thereto.
WE UNDERSTAND THAT NO PAYMENT OR CONSIDERATION OTHER THAN THE ABOVE HAS BEEN PROMISED
US OR WILL BE PAID TO US.
WE UNDERSTAND THAT THIS PAYMENT CONSTITUTES THE FULL PAYMENT AND COMPLETE SATISFACTION
OF ANY CLAIM WHICH WE NOW HAVE OR MAY HEREAFTER HAVE RELATED TO WORKER'S COMPENSATION
BENEFITS PAID TO EMPLOYEE ERIC BURKEY.
WE ARE ON NOTICE THAT THE STATUTE OF LIMITATIONS FOR FILING A CLAIM FOR DAMAGES WILL EXPIRE
ON November 4, 2025.
I have carefully read and understand the foregoing release.
Executed this Zg day of O(,{aber 2024, at Vu wjK A) 01.
READ CAREFULLY BEFORE SIGNING
•
Print Name: L01(( u G14,14aude` Signed: 4
Print Name Signed: M1hAr ?:T,'
WITNESS: Addre-
NOTE:For your protection the law requires the following to appear on this form:Any person who knowingly presents a false
or fraudulent claim for the payment of a loss and with the intent to injure, defraud or deceive any insurance
company, or files a statement of claim containing any false, incomplete, or misleading information, is guilty of a
crime,and may be subject to fines and confinement in state prison.