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