HomeMy WebLinkAboutItem #12 Workers' Compensation Release and Settlement
AGENDA ITEM COVER SHEET
Meeting Date: 9/02/08
Item # ~ ~
Reviewed By: ~_ ~
Contact Name: James Carnicella Department Directo~_:...: _ ~ /'{'I~
Contact Number: 1032 City Manager: ~ ~ __ c---
Subject: Workers' Compensation release and settlement agreement with employee Billy Adams.
Background Summary:
The employee has suffered a medical incident that could have resulted in a workers' compensation claim.
The employee and the City have negotiated an agreement whereby the employee will not seek a work related
claim and waives present and future benefits under the Florida Statues.
Issue:
By signing the attached release and accepting the settlement amount reflected the employee will waive any
present and future claims concerning workers' compensation and will resign from employment effective
September 2, 2008.
Recommendations
Staff respectfully recommends the Commission approve the attached agreement.
Attachments:
General Release and Waiver Agreement.
Financial Impact:
$52,959.89 to be paid from the Police Department salary line item.
Type of Item:
D Public Hearing
D Ordinance First Reading
D Ordinance First Reading
D Resolution
[8] Commission Approval
D Discussion & Direction
For Clerk's Deaf Use:
[2] Consent Agenda
D Public Hearing
D Regular Agenda
D Original Document/Contract Attached for Execution by City Clerk
D Original Document/Contract Held by Department for Execution
Reviewed by City Attorney
Reviewed by Finance Dept.
Reviewed by ( )
o N/A
o N/A
o N/A
GENERAL RELEASE AND WAIVER OF ALL CLAIMS
AND VOLUNTARY RESIGNATION
This General Release and Waiver of All Claims and Voluntary
Resignation ("Agreement") covers all understandings between Billy
Adams (hereinafter "Employee"). and City of Oeoee, hereinafter
"Employer") relating to Employee's employment and resignation from
employment with the Employer. No other expressed, implied, written
or oral agreement between Employee and the Employer relating to
Employee's employment and/or resignation from employment with the
Employer will have any effect unless it is in writing and is signed
and dated by both parties after the date of this Agreement.
The parties agree that for the purposes of this Agreement, all
references to City of Oeoee or the Employer should be understood to
mean not only City of Oeoee itself, but also all current, past and
future divisions, parent companies, subsidiary companies and
affiliated companies including its current, past and future
officials, employees, agents, representatives, officers, directors,
attorneys, shareholders, successors and assigns and its current,
past and future divisions, parent companies, subsidiary companies
and affiliated companies, and all persons acting by, through, under
or in concert with any of them. If any of these words are
'unfamiliar to :Employee, Employee is 'advised to consult an attorney
for an explanation.
JUN 1 3 2008
I
I
!
I
!
~
I
I
I
I
I
i
i
I
!
I
I
I
i
I
I
I
!
I
!
I
I
i
!
I
I
I
I
I
i
I
I
I
!
I
I
VOLUNTARY RESIGNATION - The claimant hereby voluntarily
resigns effective 9/2/2008 from the employer and agrees not to
seek employment as a sworn employee with the employer in the
future.
AMERICANS WITH DISABILITIES ACT, TITLE VII OF THE CIVIL RIGHTS
ACT OF 1964 AND WRONGFUL DISCHARGE RELEASE As further
consideration for the lump sum payment, the claimant releases,
settles and waives any and all claims whether or not asserted,
against the employer or any of its officers, agents, servants,
employees, directors, successors, assigns and any other person or
entity without any limitation including any and all past, present
or future Americans with Disabilities Act, wrongful discharge, and
Title VII of the Civil Rights Act of 1964 claims or lawsuits. The
claimant stipulates that he has considered returning to work
within the reasonable accommodations, provided by the employer, but
is unable to do so, even with the reasonable accommodations without
imposing an undue hardship on the employer. The employer agrees to
pay the claimant $100.00 for this release/settlement/waiver, which
is included in the overall settlement.
This is not a complete list, and Employee waives, releases and
remises, acquits and discharges all other rights and claims
Employee has or may have under all other federal, state and local
laws, regulations and ordinances, including but not limited to
statutory and common law contract, tort, and/or wrongful discharge
claims arising out of or relating in any manner to Employee's
employment and/or resignation from employment with the Employer.
The Employee hereby acknowledges and stipulates that the
Employer has not discharged, threatened to discharge, intimidate or
coerce him by reason of such Employee's claim for compensation or
attempt to claim compensation under the Florida Workers'
Compensation Law.
This Agreement shall be construed according to Florida law.
The parties agree that if any clause or provision herein is deemed
by a court of competent jurisdiction to be illegal, invalid or
unenforceable, the legality, validity and enforceability of the
remaining parts, terms or provisions shall not be affected thereby,
and the remainder of this Agreement shall remain in full force and
effect.
Employee, by signature below, acknowledges that Employee has
carefully read and considered the contents of this Agreement, and
that Employee fully understands all of its provisions and is
voluntarily, willingly and knowingly entering into this Agreement.
The parties have concurred in drafting this Agreement and it
therefore should not be construed against any of the parties to
this Agreement.
Signed, sealed and
delivered in the
presence of:
I HAVE READ THIS GENERAL RELEASE
AND WAIVER OF ALL CLAIMS AND
RESIGNATION AGREEMENT
!
I
I
I
t
I
I
I
It is the intent of the parties to make this resignation
effective on the date the Employee signs this Agreement.
~.1n~
~-~
Bil Y ~S
(SEAL)
STATE OF FLORIDA
COUNTY OF O..o.,,~
I HEREBY CERTIFY that on this day, before me, an officer duly
authorized in the State of Florida and County aforesaid to take
acknowledgments, personally appeared Billy Adams, who, upon his
oath, deposes and says that he is the person described herein and
that he executed the foregoing General Release and Waiver of All
Claims and Resignation Agreement in the presence of a subscribing
witness, for the purposes stated therein, and acknowledged that he
executed the same freely and voluntarily.
ss:
IN WITNESS WHEREOF, I have
official seal in the State
this ~~ day of ~u u
Expires:
I ~."." -~ No~ry Public State 0/ Florida
. -J. Chnstina L Brando/in;
'\ <!f-I My Commission DD664741
0, '" Exolres 04/18/2011
JUN 1 3 2008
REPORT TO CHIEF JUDGE OF
APPROVAL OF LUMP SUM SETTLEMENT UNDER SEC. 440.20(11) (a), F.S.
Date of Report
Style of Case:
OJCC CASE NO. :
D/A: 02/05/08
JUDGE ASSIGNED:
Claimant: Billy Adams
Employer:
City of Ocoee
Carrier:
The PMA Insurance Group
Date lump sum settlement approved
Amount of settlement:
$50,000,00
Past, present and future compensation
$25,000.00
Past, present and future medical
$25,000.00
$0.00
$2,959.89
Rehabilitation
Out of pocket medical expenses
TOTAL
$52,959.89
$0.00
I
I
I
I
I
I
i
I
I
I
i
I
I
I
i
I
i
I
I
I
I
I
I
I
I
I
I
!
Amount of attorney fee paid by claimant
Judge's statement of the nature of the controversy as to legal or
medical compensability of the claimed injury or the alleged
accident.
The employer/carrier contend: The claimant's employment is not the
major contributing cause Of his condition and need for treatment.
The claimant's condition is pre-existing and personal in nature.
Signed
Judge of Compensation Claims
District ""
Attachment: Copy of Executed Settlement Agreement
LES FORM OCC-18 (REV. 1/91)
OJCC CASE NO.:
PAGE 1
JUN 1 3 2008
STAn: or rLORIDA
DIVISION or AIlKIJaSTJtATIVB BBAJtIHGS
OI'I'ICB 01' TB:I Jll])OBS or COKPBHllATION CLAIKS, DISTRICT
CLAIMANT:
Billy Adams
Post Office Box 335
Ocoee, FL 34761
ATTORNEY FOR CLAIMANT:
NO COUNSEL OF RECORD
EMPLOYER:
City of ocoee
150 North Lakeshore Drive
Ocoee, FL 34761
ATTORNEY FOR EMPLOYER/CARRIER:
Rissman, Barrett, Hurt, oonahue & MCLain, P.A.
201 E. Pine Street, Suite 1500
P.O. Box 4940
Orlando, FL 32802-4940
OJCC CASE NO:
CARRIER:
The PMA Insurance Group
2701 N, Rocky Point Drive
Suite 250
Tampa, FL 33607
JUDGE ASSIGNED:
D/ACCIDENT: 02/05/08
ORDER FOR RELEASE FROM LIABILITY FOR ALL WORKERS' COMPENSATION BENEFITS
UNDER SECTION 440.20(11) (a) (2001), FLORIDA STATUTES
The parties jointly petition for an order approv~ng a stipulation for settlement under Section
440.20(11) (a), Florida Statutes. Following review of the contents of the stipulation and supporting
evidence, including the sworn statement of the employee (petitioner/claimant) incorporated into the
stipulation, the following findings are made:
1. All requirements of section 440.20(11) (a), Florida Statutes, and Florida Rule of Workers'
compensation Procedure 4.143 have been complied with.
2. The employee (petitioner/claimant) fully understands the terms, conditions, consideration
for, and consequences of the proposed settlement.
3. The employer/carrier/servicing agent filed a written notice of denial within 120 days after
the date of the injury.
4. The payment of attorney fees as set forth in the joint petition and stipulation for
settlement is supported by the evidence and is in compliance with the requirements of chapter 440, Florida
Statutes.
5. The proposed settlement is not in excess of the value of benefits the employee would be
entitled to receive under chapter 440, Florida Statutes.
6. There is a bona fide justifiable controversy as to the legal and medical compensability of
the claimed injury or alleged accident. ,
7. The proposed settlement will'definitely aid in the rehabilitation of the employee or
otherwise is clearly in the best interests of all parties.
8. These findings are limited to matters included within the jurisdiction of the Judge of
Compensation Claims under chapter 440, Florida Statutes. The undersigned Judge of Compensation Claims makes
no findings regarding the legal sufficiency or reasonableness of any other matters that may be included in
the stipulation in support of the Joint Petition in this case.
IT IS ORDERED AND ADJUDGED:
A. The joint petition and supporting stipulation for settlement are hereby
granted/denied/granted in part, based upon the following disposition:
, and the part1es are ordered to comply with the provisions of those
documents.
B. On payment of the consideration set forth in the joint petition and supporting stipulation
for settlement, the liability of the employer and its carrier (servicing agent) for the payment or provision
of any class of benefits including medical benefits payable under the Florida Workers' Compensation Law
because of the alleged industrial accident and injury referred to in this order ie fully and forever
discharged and released.
C. This order shall not be subject to modification or review under Section 440.28, Florida
Statutes.
DONE AND ORDERED in Chambers.
JUDGE OF COMPENSATION CLAIMS
THIS IS TO CERTIFY that the above Order was entered in the office of the Judge of Compensation
Claims and a copy was served by U.S. Mail on each party and counsel at the addresses listed above on
, 2008.
Assistant to the Judge of Compensation Claims
OJee CASE NO.:
PAGE 1
JUN 1 3 2008
I
I
I
!
l-
I
t
STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
OFFICE OF THE JUDGES OF COMPENSATION CLAIMS, DISTRICT 1111
ATTORNEY FOR CLAIMANT:
CLAIMANT:
Billy Adams
Post Office Box 335
Ocoee, FL 34761
NO COUNSEL OF RECORD
ATTORNEY FOR EMPLOYER/CARRIER:
Rissman, Barrett, Hurt, Donahue
& McLain, P.A.
201 E. Pine Street, Suite 1500
P.O. Box 4940
Orlando, FL 32802-4940
EMPLOYER:
City of Ocoee
150 North Lakeshore Drive
Ocoee, FL 34761
CARRIER:
The PMA Insurance Group
2701 N. Rocky Point Drive
Suite 250
Tampa, FL 33607
OJCC CASE NO:
JUDGE ASSIGNED:
D/ACCIDENT: 02/05/08
STIPULATION IN SUPPORT OF JOINT PETITION FOR ORDER APPROVING
A LUMP SUM SETTLEMENT UNDER F.S. 440.20{11) (a)
The above named parties hereby seek approval of the following
agreement made for the specific purpose of discharging the
employer/carrier for any liability for all benefits under the
Florida Workers' Compensation Act in,exchange for the payment of a
lump sum of money to the claimant. The parties hereby stipulate
and agree as follows:
1. JURISDICTION - The Judge of Compensation Claims appointed
under F.S. 440.45 has jurisdiction of the subject matter and the
parties hereto.
2. DESCRIPTION OF ACCIDENT - The claimant developed a heart
condition requiring surgery.
3. POSITION OF EMPLOYER/CARRIER - The employer/carrier have
contested the compensability of the claim and as evidence thereof
filed a written Notice of Denial within 120 days after the date of
the inj ury .
The employer/carrier contends that the claimant's
employment is not the major contributing cause of his condition and
need for treatment. The claimant's condition is pre-existing and
OJCC CASE NO.:
PAGE 1
JUN 1 3 2008
f
!
r
i
I
I
I
i
I
personal in nature. A copy of the Notice to Controvert is attached
and made a part hereof.
4. AVERAGE WEEKLY WAGE AND COMPENSATION RATE - At the time
of the injury, the claimant's average weekly wage was $1,074.42
thus making the compensation rate $716.31 per week.
5.
AGE, EDUCATIONAL BACKGROUND AND WORK HISTORY
The
claimant is 59
years of age (DOB: 11/17/48
) and has a
-23 grade education. He is able to read, write and make change.
His work history includes employment as a
utility Service Worker I
Water Tech I
At the time of the injury, the employee was
working as a police officer.
6. SETTLEMENT AMOUNT AND DISCHARGE FROM LIABILITY FOR FUTURE
COMPENSATION - Subj ect to the approval of the Judge of Compensation
Claims, the employer/carrier will pay to the claimant $50.,000.00 in'
accordance with the statutory formula in full satisfaction of the
obligation or liability to pay all benefits of whatever kind or
classification available under the Florida Workers' Compensation
Act including, but not limited to, medical benefits, monetary
compensation as contemplated under Section 440.15, Florida
Statutes, impairment benefits, death and dependency benefits,
penalties, interest, costs, and rehabilitation benefits under
Section 440.491, Florida Statutes, on account of the alleged
accident or occupational disease referenced herein which shall be
allocated as follows:
(a) Past and Future Compensation benefits '$25,000.00
(b) Past and Future Medical expenses $25,000.00
(c) Rehabilitation expenses and temporary
total disability benefits during
rehabilitation $0.00
(d) Out of Pocket Medieal expenses $2,959.89
(deductible,eo-insuranee,ER,co-pays,prescriptions)
OJCC CASE NO.:
PAGE 2
JUN 1 3 2008
TOTAL $52,959.89
The parties agree that the employer/carrier will have
thirty days from the date copies of the Order approving this
Joint Stipulation are mailed to the parties to make payment
wi thout incurring interest and/or penal ties and agree to waive
any statutory provisions to the contrary.
The parties represent to the Judge of Compensation Claims
that a justiciable controversy exists regarding the claimed
inj ury or alleged accident. Upon receipt of the lump sum, the
employer/carrier will be forever released and discharged from
the obligation or liability to pay any and all benefits of
whatever kind or classification payable under the Florida
Workers' Compensation Act. The Employer agrees to reimburse the
Employee any out of pocket medical expense including the health
care deductible, coinsurance deductible, emergency room fee, co-
pays and prescription co-pays.
It is stipulated by and between the parties that each side
shall pay its own costs in connection with this claim.
The parties stipulate and agree that the claimant is
responsible for liens of his prior attorneys.
7. WAIVER OF RIGHT TO HAVE CASE BEARD BY JUDGE OF
COMPENSATION CLAIMS AND RIGHT TO BRING PETITION FOR MODIFICATION
The claimant understands that he does hereby relinquish the
right to have unresolved conflicts or disputes involving the
right to monetary compensation benefits, impairment benefits,
death benefits, past due medical benefits, future medical
benefits and rehabilitation benefits heard and decided by a
Judge of Compensation Claims. The Judge of Compensation Claims
will only retain the authority to hear and decide any issues
involving disputes regarding this agreement. When approved by
the Judge of Compensation Claims, this agreement shall not be
subject to modification under F.S. 440.28.
I
I
.
I
I
I
I
r
I
f
I
t
OJCC CASE NO. :
PAGE 3
8 . PRESENT WORTH AND POSSIBLE OFFSET FOR SOCIAL SECURITY
DISABILITY BENEFITS CONSIDERED - In reaching this agreement, the
parties have considered the present value of all future payments of
monetary compensation, impairment benefits, and death benefits
potentially payable to the claimant on account of the accident or
occupational disease referenced herein.
Consideration was also
given to the possible loss of supplemental benefits due under
Section 440.15(1) (f)l., F.S. (2001) and to the right of the Social
Security Administration to offset disability benefits due under
that law for workers' compensation benefits payable under state
law. The present value of the future compensation benefits
potentially payable on account of the accident or occupational
disease referenced herein was discounted sufficiently to take into
consideration the employer/carrier's right to offset compensation
benefits due under the Florida Workers' Compensation Act against
benefits payable on account of total disability under Chapter 42 of
the United States Code.
I
9. WAIVER OF PENALTIES. INTEREST. AND FORMAL NOTICE - The
claimant does hereby waive any right he may have to any and all
penalties or interest on account of the alleged accident or
occupational disease referenced herein. The parties may present
this Stipulation to the Judge of Compensation Claims for
consideration and approval without necessity of a formal notice
which requirement is hereby expressly waived.
10 . EMPLOYER GIVEN FORMAL NOTICE OF PROPOSED LUMP SUM
SETTLEMENT - The parties represent that the terms and conditions of
this settlement have been disclosed to the employer and, as
required, the employer has been advised of the right to appear at
a hearing before the Judge of Compensation Claims to present
OJCC CASE NO.:
PAGE 4
JUN 1 3 2008
testimony regarding said settlement. A copy of the letter giving
the employer notice of the right to appear is attached.
11. STIPULATION SUBJECT TO APPROVAL OF JUDGE OF COMPENSATION
CLAIMS - The parties clearly understand that this agreement must
be approved by the Judge of Compensation Claims before it becomes
formally binding. The claimant understands that agreements have
been routinely disapproved by judges in the past and should not
undertake any financially binding actions until formal approval is
obtained.
In the event this Stipulation is not approved in its
entirety by the Judge of Compensation Claims, it shall be
completely void and of no effect whatsoever. If the Stipulation is
disapproved, the employer/carrier reserves the right to assert any
and all defenses available under the Florida Workers' Compensation
Act.
12 . CONDITIONAL
AGREEMENT
The
claimant
and
the
r
~
I
I
I
employer/carrier stipulate and agree that in the event this
Stipulation agreement is determined to be unconstitutional or
invalid by the District Court of Appeal or the Florida Supreme
Court, or is otherwise not given full force and effect or is voided
for any reason, in part or in whole, the employer/carrier shall be
entitled to full reimbursement of the lump sum paid to the claimant
provided for herein, within 30 days of request by the
employer/carrier.
If any portion of the settlement proceeds are
not
immediately
returned
to
the
employer/carrier,
the
employer/carrier shall be entitled to a 100% offset against the
claimant's compensation benefits and medical benefits until the
settlement amount is fully repaid. Under no circumstances shall
the settlement amount provided for herein be considered a
gratuitous payment by the employer/carrier.
OJCC CASE NO.:
PAGE 5
JUN 1 3 2008
JOINT PETITION
Under the provision of F.S. 440.20(11) (a), the parties hereby
jointly petition the Judge of Compensation Claims for the entry of
an Order approving this Stipulation which will discharge and
release the employer/carrier from all further liability to the
claimant for all benefits available of whatever kind or
classification including, but not limited to, future medical
benefits, compensation for disability under Section 440.15, Florida
Statutes, impairment benefits, past medical benefits, death
benefits and rehabilitation benefits due under the Florida Workers'
Compensation Act upon payment of the lump sum herein provided which
shall not be subject to modification under F.S. 440.28.
OJCC CASE NO.:
PAGE 6
JUN 1 3 2008
[
I
~
!
I
I
I
f
I
I
I
i
I
This Stipulation and Joint Petition was signed by the
employer / carrier on the
day of
, 2008 and
by the claimant on the ;~ day of
~G-CiV" /'
, 2008.
~-~
Billy ~ms
Claimant
Jill M. Spears
Attorney for Employer/Carrier
(407) 839-0120
STATE OF :F'l()(ldo..
COUNTY OF Of"'Q\'\~ ~
The foregoing instrument was acknowledged before me this ;d.S
day of -Au~~~ , 2008 b~1 \\fci ~(Y\~ , who is
personally own to me or who has produce
as identification and who did take an oath, and who upon being duly
sworn certifies that the information furnished by him as
incorporated in the foregoing Stipulation is true and correct and
that he (has read the Stipulation) (has had the Stipulation read to
him) and believes the lump sum settlement to be in his best
interest.
Notary Publ
4/tfb/20\\. '
My Commissi
Notary Public Stale of Florida
Christina L Bran1o"llini
My Commiseion 00664741
OJCC CASE NO.:
PAGE 7
JUN 1 3 2008
AFFIDAVIT
STATE OF
COUNTY OF
BEFORE ME, the undersigned authority, personally appeared
Billy Adams who, being first duly sworn, deposes and says:
1. My name is Billy Adams, and I am the claimant in workers'
compensation claim in which City, of Ocoee is the employer, and The
PMA Insurance Group is the carrier concerning an industrial
accident that occurred on 02/05/08.
2. My claim has been settled for a total lump sum payment to
me in the amount of ~52,959.89
3. I have read the Joint Petition for Lump Sum Settlement
and fully understand the same and am in agreement therewith.
4. I understand that receipt by me of the lump sum
settlement completely discharges and terminates any liability or
responsibility that the employer or the carrier may have toward me,
as a 'result of this accident and/or condition;
5. I understand that I am under no compulsion to settle my
claim, and I am settling this case voluntarily and of my own free
will.
6. I understand that under the Florida Workers' Compensation
Law, I have the right to pursue my claim, to go to hearings and
have the Judge of Compensation Claims determine what further
benefits, if any, I am entitled to and that this settlement is not
my only remedy or way of handling my claim.
OJCC CASE NO.:
PAGE 1
JUN 1 3 2008
7. I understand that by agreeing to settle my claim, I am
wai ving and giving up any rights that I would have to further
pursue my claim, including rights to future medical benefits.
8. I understand that if the Judge of Compensation Claims
enters an Order approving this settlement, that this is a final
Order and not subject to modification, change or review.
9. I waive my right to a formal hearing.
10. I now reside at:
11. I believe the Joint Petition to be in by best interest
and request the Joint Petition be approved. It is my desire and
request that the Judge of Compensation Claims enter an Order
approving this settlement and I request that the settlement be
approved without the need for a formal hearing, which I
specifically hereby waive.
12. I~(am not) gainfully employed at the present time.
(Please circle appropriate answer)
FURTHER AFFIANT SAYETH NAUGHT.
~..
Billy A~
Claimant
~
STATE OF Flex',ao
COUNTY OF ().ra.~
The for~~ing instrument was ackn~edged before me this ~-th
day of +\.t~S , 2008 by ,- 't)l \l'-( M.ciY\~ ,
who is personally ~own to me or who has produced
as identification and who did
take an oath.
Notary Publi
41''bI-wtl
My Commissio
OJCC CASE NO.:
PAGE 2
JUN 1 3 2008
AFFIDAVIT
STATE OF
COUNTY OF
BEFORE ME, the undersigned authority, personally appeared
Billy Adams who, being first duly sworn, deposes and says:
1. My name is Billy Adams. I am the claimant/employee in a
workers' compensation claim, where the OJCC number is , now pending
before the Judge of Compensation Claims.
2. I acknowledge that:
~~
Billy Ada s
Claimant
!
I
I
I
I
l
I owe child support.
~
I do not owe child support.
(PLEASE INITIAL ONE ABOVE)
FURTHER AFFIANT SAYETH NAUGHT.
STATE OF niX\dO-
COUNTY OF Ofo~
The foregoing instrument was acknowledged before me this ;;;;t54l..
day of -Au~J..~+ , 2008, by Billy Adams, who is
-personally known to me or who has produced
as identification and who
did take an oath.
Notary
LU/CO l2(:) \ \
My Commission
of Flofida
Christina L BrandOllni
My Commission 00664741
Ex 04/18/2011
OJCC CASE NO:
PAGE 1
JUN 1 3 2008
GENERAL DOCUMENT FILING
General Settlement Order Information UnreDresented Claimant
Amount of Total Settlement:
$
$
$
$
Amount of Outstanding Child Support Obligation:
Amount of Settlement Allocated to Child Support:
Amount, if any, allocated for Future Medical Expenses:
INFORMATION SPECIFIC TO UNRBPRBSBNTED SETTLEMENT ORDERS
If this is a subsection (a) settlement (compensability denied), identify
the nature of the controversy (check below) .
Not in course and scope of employment
Injury not timely reported
Not an employee
Positive Drug Test
Misrepresentation on Application for employment
No Accident
Casual Connection Lacking
No Injury occurred
Statute of Limitations
Unspecified
If this is a subsection (b) settlement (employee has attained Maximum Medical
Improvement), enter the date below
I mm/dd/yyyy
OJCC CASE NO:
PAGE 1
JUN 1 3 2DD8
I
I
i
I
i
!
I
I
I
I
I
!
I
I
I
I
,
I
~
I
!
''lo_W_..'''- ....WI ..._. _....."""'_ ..,............ WW_.. .--.-
06/131200B 10:40 FAX 4078419728 'R.B.H.D.lN.
~- ..w '--~.-Iit002/002
STATE O~ rLOR~DA - DBPARTMBNT OV R3VENOB
State of Florida
Department of Labor and Employment Security
Ofi1ce of the JUdge of Compensation Claims
Honorable
Reguested By:
Jill M. Spears. Esquire
Ri 55rnan, Barrett, Hurt, Donahue & McLa in.
P.A.
201 E. Pine Street. Suite 1500
P.O. Box 4940
Orlando, FL 32802-4940
Fax No.: (407) 841.9726
Carrier:
The PMA Insurance Group
2701 N. Rocky point Drive
Suite 250 .
Tampa. FL 33607
Emp1oyee/Cla1mant:
B1lly Adams
Post Office Box 335
Ocoee. FL 34761
Socia 1 Security i: _-0806
Date of Birth: 11/17/48
RE: .WORKERS' COMPENSATION CLAIMS/DELINQUENT CHILD SUPPORT CASE
NON-CUSTODIAL PARENT: SSN: I. 0806 DOS: 11/17(48
SSN:
CUSTODIAL PARENT
Dear Judge :
The records of the Department of Revenue 1nd1cate an active account, case :#
. for the aforementioned parties. As of
, 'an arrearage of S exists.
/" The records of the Department of Revenue do not reflect
aforementioned parties as of 5" /13/Qi
any account for the
Sincerely.
~&
913/913 39'i;fd
35N0dS3~ ::)M 35::)
JUN 1 3 2008 /
8Pla0P1pe9a 9~:Lla 80lal/Pl/9la
05/13/2008 10:43 FAX 4078419726
R.8.H.D.aM.
IaJ 002/003
Orange County
Clerk of the Circuit Court and Comptroller
CHILD SUPPORT DEPOSITORY
Date: May 13, 2008
By:
The State IV -D database indIcates !here Is
County.
I
I
r
I
i
I
I
I
i
I
I
,
I
I
~
I
I
I
f
I
I
i
I
I
I
I
I
I
I
I
i
I
I
I
I
i
!
i
,
I
i
I
I
State of Florld~
Department of Labor and Employment Security
Office of the Judge of Compensation Claims
Requested by:
Jill M. Spears, Esquire
RIssman, Barrett, Hurt,
Donahue & Mclain, P A.
201 E. PIne Street, Suite 1500
P.O. Box 4940
Orlando,FL 32802-4940
E mployeelClalm8nt:
Mr. Billy Adams
Post Office Box 33!5
Ocoee, FI. 34761
Social SeClJrity # 283-7'8-0'08
Dats of Birth: 11/17/48
Carrier:
Malanis Aponte-O.vila
The PMA Insurance Group
2701 N. Rocky Point Drive
Suite 260
Tampa, FL 33607
RE: WORKERS' COMPEN$A liON CLAIMS/DELINQUENT CHILD SUPPORT CASE
NON-CUSTODIAl. PARENT:
CUSTODIAL. PARENT:
Social Security #_-_-_
Soelll Security #_-_-_
Dear Honorable:
THE IW:ORDI or ~ CINTRAL DEPOIITORY INDICATA AN ACllVE ACCOUNT, CAB. NlJUIIR
APOIWIINTIOtelJlAlll1Q.. Aa Of' _I_I---.J AN AMIAIWSI!QlI$
CERT1FIiO Al'l'lDAYIT.
. !'OR THE
iXI8TS. JlVRe\lANTTO THE ATTACHED
'to..'r ..
_..~ ......
x
TItI AI'OImIIiHTIONIiD "AA'I'IE& All 01'
Signature and Title
JUN 1 3 2doaJ