[date]

[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. 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.

11. 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].

[signature]

Releasor

Approval of Board

[signature]

[title]

[Acknowledgment]