Okaloosa County BOCC — March 18, 2014 — Settlement Agreement — reading text

the claimant at a rate of $20.05 per week over his expected lifetime. The same is true for the lump sum payment of future medical benefits, which, when reduced to present value, is equal to $262,250.00. The iump sum consideration given for the settlement of future medical benefits is the same as if the lump sum would have been paid to the claimant at a rate of $210.14 per week over his expected lifetime. The employer's/carrier's/servicing agent's right to offset workers’ compensation indemnity and medical benefits due under Florida Workers' Compensation Law against benefits payable on account of total disability under Chapter 42, UNITED STATES CODE, including benefits payable under Medicare, is also included in these calculations and has been considered by the parties in reaching this agreement. 12. M N P P M EN ; R F TH AND REHABILITATIVE SERVICES UNDER F.5.8409,910 ( MEDICAID THIRD PARTY LIABILITY ACT) - The claimant confirms that no claim or right of reimbursement by Medicare or Medicare Secondary Payer Program exists, or lien of the Department of Health and Rehabilitative Services under F.S.§409.910 for treatment of the injuries arising from the work related accident referred to herein. Claimant hereby acknowledges that all responsibility for Medicare claims or Medicare Secondary Payer Program and/or all claims or liens of the Department of Health and Rehabilitative Services under F.S. §409.910, for any and all past treatment for which Medicare or Medicare Secondary 4 Payer Program and/or the Department of Health and Rehabilitative Services under F.S. §409.910 has a claim, if any, is that of claimant, subject to the rules and regulations of Medicare and/or the Department of Health and Rehabilitative Services under F.S. §409.910. Claimant indemnifies and holds harmless the employer/carrier/servicing agent against any liability in favor of Medicare or Medicare Secondary Payer Program and/or the Department of Health and Rehabilitative Services under F.S. §409.910. 13. 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. 14, ENT: RIES NAL DIS EVEA AN PE LA’ T - The claimant once again represents and affirms that all accidents, injuries and occupational diseases known to have occurred or sustained while employed by the employer have been revealed. All pending claims and notices of denial pertaining thereto are hereby voluntarily withdrawn. 15. AGREEMENT SUB TO APPROVAL OF [UPGE OF COMPENSATION CLAIMS. - The parties clearly understand that attorney fees and costs, as well as child support obligations of claimant must be approved by the Judge of Compensation Claims, before settlement becomes formally binding. The claimant understands that these items 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 these items are not approved by the judge the settlement shall be completely void and of no effect whatsoever. If such approval by the Judge is not forthcoming, the employer/carrier/servicing agent reserves the right to assert any and all defenses available under the Florida Workers’ Compensation Law. 16. MP ST. D ED TTLEMENT PROCEEDS - The claimant is currently unemployed. If the terms of this settlement are approved, the claimant plans to use the proceeds therefrom as follows: savings and to pay bills. The information set forth above was provided by claimant in response to the settlement questionnaire directed to claimant by attorney for employer/carrier/servicing agent. 17. SIMULTANEOUS LANGUAGE - This agreement is made contemporaneously to simultaneous agreement between claimant and employer/carrier entitled Motion for Approval of Attorney's Fee and Allocation of Child Support Arrearage for Settlements Under Section 440.20(11)(c), (d), & (e), Florida Statutes 2001, signed by the parties on the ______ day of , 2013. This lump sum settlement shall be void and of no effect in the event the above referenced Motion should not be approved simultaneously herewith. 18. SETTLEMENT AGREEMENT - The execution of this Settlement Agreement will discharge and release the employer/carrier/servicing agent from all further liability to the claimant for all past and future 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, attorney's fees, death benefits and rehabilitation and training and education benefits including temporary total disability compensation under Section 440.49(1989)&(1990) and 440.491(6)(b)(1993) due under the Florida Workers’ Compensation Law upon payment of the lump-sum herein provided which shall not be subject to modification under FS. §440.28. This Settlement Agreement was signed by the employer/carrier/servicing agent on the _.... day of __, 2013, and by the claimant on the _ /4 __ day of __ Feb ___ 20144 ee Ly l/ a & STEVEN ST. CLERGY ; hdwacd H. Hurt, Jr, bsq. oo Post Office Box 677489 Orlando, FL 32867 407-673-3408 Fla. Bar #0340936 Attorney for Employee/Claimant Cass rigr Charles K. Windes, Jr., Chairman Roderic G. Magie, Esq. Okaloosa County Board 3 West Garden St, Suite 614 Of Commissioners Pensacola, FL 32502 850-432-2558 Florida Bar #094862 Attorney for Employer/Carrier/SA STATE OF K. y COUNTY OF _// 0 p King Before me, the undersigned authority authorized to administer oaths and take icknowledgements, personally appeared STEVEN ST. CLERGY, who (is personally known to me) (was identified by driver's license) (who has produced O¥tyer Liga identification) on this 14 day of Feb 20 Atwho upon being duly sworn certifies that the information furnished by him as incorporated in the foregoing agreement is correct and that he (has read the agreement) (has had the agreement read to him) and believes the lump-sum settlement to be in his best interest. Lauls $ lyk ( natin Number 4A V3 IK’ My Commission Expires: /e- G-J0 4 6 The undersigned, STEVEN ST. CLERGY, for the sum of ONE HUNDRED AND 00/100THS Dollars ($100.00), paid to him by OKALOOSA COUNTY BOARD OF COMMISSION ERS, and other s0o0d and valuable consideration, the receipt and sufficiency of which is expressly ackriowledged and confessed, does hereby réledse and forever discharge - OKALOOSA COUNTY BOARD OF COMMISSIONERS and its felated corporations and its officers, agétits and associates both past and present; from all claims, demands, causes of action, including without restricting the foregoing generality, any and all claims for back pay, paid time off (PTO), workers’ compensation benefits (including medical), salary céntinwation benefits, health insurance benefits, sick leave accrued, long tern: disability benefits. (LTD). avid other fringe benefits, liquidated damages, exemplary damages, punitive damages, consequential daniages, datiages for mental atigdish, damages for loss of employment prospects; damages: for loss of reputation, damage for breach of contract, negligence, mistepresentation, intentional acts, attorney fees of any kind, whether known of unknown and whether asserted or'nét. . STEVEN ST. CLERGY hereby promises riot torfile, or authotize any other individual, ageney,.or private or'gevernmental entity to file on his behalf, any state or federal lawsuit orany state, federal or muni¢ipal administrative charge or complaint against OKALOOSA COUNTY BOARD OF COMMISSIONERS and hereby waives and-releases any and all claims, rights, arid causes of action, in law or equity of any Kind, whatsoever; which STEVEN ST. CLERGY or his heirs, executors, administrators, assigns or other legal represeitatives have-or niay have apainst .CKALOOSA-COUNTY BOARD OF COMMISSIONERS at this: tinie: or which are based on ‘any past acts: or ornissions of STEVEN ST. CLERGY, including, but-not:limited to, those arising out of his employment with or separation from OKALOQSA:COUNTY BOARD OF COMMISSIONERS including, but not limited’ to thdse elaims,. rights;, anid causes: of action’ based on any federal, state or local law, statute, ordinance, administrative regulation; public’ policy or Executive Order, such Ss the Fair Labor Statidards Act. of 1988, as artiended, 29°USIC. Sec. 201-209: the Civtl Rights Act of 1964,.as amended, 42. U-S.C. Sect. 2000e-2000e-17; the.Civil Rights Act of 1991, thé Civil Rights Act of 1866, as amended, 42 U.S.C. See. "1981; the Civil Rights Actof 1671, as amended, 42 U.S.C. Séc. 1983, 1985; Executive Order 11246; the Rehabilitation Act of 1973, as amended, 29 U.S.C. Sec. 701-7961; thé National Labor Relations Act, as amended, 29 U:S.C. Sec. 141-187; the Age Discrimination ia Employment Act of 1967, as amended, 29 U.S.C: Sec, 621-634; (the Florida Humnan Rights Act, as amended, Fla. Stat. Sec. 760.01-760.10;) the Americans with Disabilities Act of 1990, 42U.S.C. Sec. 12111 et seq,; retaliatory discharge claim or wrongful discharge claim; claitis under Section 440.205, Florida Statutes, retaliatory discharge claims, or any other state or federal constitutional claim, right, public policy or cause of action founded in tort, contract, or othér common law cause of action including, but not limited to, actions: based on misrepresentation, defamation, invasion of privacy, interference with prospective economic advantage, interference with contractual relations, or negligence. This document shall not inipair or impede claimant's right to unemploymient compensation that might otherwiséexist. STEVEN ST. CLERGY understands. and grees that the.consideration provided by. OKALOOSA COUNTY BOARD OF: COMMISSIONERS to him is ia, fall accord. atid. satisfaction. of doubtful and . disputed claims, and that the-consideration for this release is for the purpose of enabling OKALOOSA COUNTY BOARD OF COMMISSIONERS. to avoid the expense and inconvenience of litigation, and does not coristitite an admission of liability on ‘its patt ard’ ‘that OKALOOSA COUNTY BOARD OF COMMISSIONERS expregsly:denies that it has violated any law with respect to:‘STEVEN ST. CLERGY. Infurther consideration of the premises STEVEN ST. CLERGY desires to sever his employment relationship with OKALOOSA COUNTY BOARD OF COMMISSIONERS after an effort by OKALOOSA COUNTY BOARD OF COMMISSIONERS to reasonably accommodate him. Also, STEVEN ST.. CLERGY waives any right to reinstatement or reemploymietit and. agrees: not to apply for, solicit, seek or otherwise attempt:to obtain employment -with OKALOOSA COUNTY: BOARD OF COMMISSIONERS or any ofits related agencies.and ‘further agrees that-OKALOOSA COUNTY BOARD OF COMMISSIONERS is not or will not be at.any time:under any obligation to employ hirn. . STEVEN ST. CLERGY utiderstatids and agrees that.the aforesaid amount shall represent full damages.and attorney fees in this inatter, with réspect to items covered by this General Release and Waiver of Employment. STEVEN ST. CLERGY understands and agrees that the anjount is not In any manner baséd_on lost:cornpensation as the measure of damages; rather, the amounit is to. be-paid by OKALOOSA GOUNTY BOARD OF COMMISSIONERS and accepted by STEVEN ST. CLERGY to avoid further costs and uncertainties of trial and the uncertainties of liability and smeowely of any relief Sought or contemplated by STEVEN ST. CLERGY. It is understood further that all federal, state and local taxes, if any, on the amount of this ' claim are the sole responsibility of STEVEN ST. CLERGY. This Reléase shall Ee binding upon the heirs, executors, administrators and assigns of STEVEN ST, CLERGY. SIGNED THIS 2 DAY OF _=lom woes 2014 Post Office Box x e7PA89 Orlando, FL 32867 407-673-3408 Fla Bar#. OSHOISE Attorney for Employee/Claimant STEVEN ST. CLERGY UNDERSTANDS THE CONTENT AND THE EFFECT OF THIS GENERAL RELEASE. HE HAS CONSULTED