Document LKdxd3ZNE46VpdRj9dvL7JOVb

REDACTED AFFIDAVIT OF Under oath, swear to the following as true. This sworn affidavit has been prepared in connection with an agreement by myself and Travelers Insurance Co. in its capacity as workers' compensation insurance carrier for Sherwin-Williams Co., to a final lump sum settlement of any and all claims, including any and all claims under the Workers' Compensation Act that I may have against Travelers Insurance Co. or SherwinWilliams Co. based on an injury sustained by myself on or about January 29, 1990 arising out of and in the course of my employment with Sherwin-Williams Co., as well as any other injuries, known or unknown, which I may have sustained at Sherwin-Williams Co.. Concerning my final lump sum settlement, I have not been promised anything other than what is expressly set forth in the Commutation of Benefits form WCB-10 submitted to the Workers' Compensation Board for approval. Further, I am aware of the right granted to me by the Workers' Compensation Act concerning my ability to return to work with Sherwin-Williams Co. and am aware that I have waived all such rights as part of this lump sum settlement. Moreover, I recognize that by agreeing to this final lump sum settlement, I am settling any and all claims that I have under the Workers' Compensation Act, including claims for weekly compensation benefits, permanent impairment benefits, reimbursement for any and all medical expenses, and reimbursement for rehabilitation expenses. I recognize that any future medical 0007-SWP-005802930 REDACTED expenses and rehabilitation expenses related to the abovementioned injury will be my responsibility, and in no way the responsibility of Travelers Insurance Co. or Sherwin-Williams Co. Further, I acknowledge that I am represented by a competent attorney, licensed to practice in the State of Maine, with whom I have discussed this final lump sum settlement and its consequences, and who has advised me concerning the same. Finally, I believe that this lump sum settlement is in my own best interests. I have read this sworn affidavit in full, and do represent that it is my own, and is true in its entirety. DATED: October 6, 1994 STATE OF MAINE ss. October 6, 1994 Personally appeared before me the above-named ~ and made oath that the foregoing statements by him are true and correct to the best belief. Notary Pub1 itr/Attorney at Law 0007-SWP-005802931 CONFIDENTIAL