Agreement For Settlement Form - Iowa Workers' Compensation Commissioner
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1
2BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER
________________________________________________________________
:
_____________________________
:
Claimant,
: Contested Case File No.___________
:
vs.
: Compliance File No._______________
:
____________________________
:
Injury Date: _________________
Employer,
:
:
and
:
AGREEMENT FOR SETTLEMENT
:
Iowa Code Section 85.35(2)
____________________________
:
Insurance Carrier,
:
Defendants.
:
________________________________________________________________
The undersigned parties submit this Agreement for Settlement to the Workers’
Compensation Commissioner for approval. The parties agree:
1. Claimant sustained an injury arising out of and in the course of employment
with Employer on _______________________
.
(date)
2. Jurisdiction exists because the injury occurred in Iowa OR Iowa Code section
85.71(___) applies. (
)
Circle one.
3. Claimant is married/single
entitled to ____exemption(s) and gross
(circle one),
weekly earnings are $___________ using Iowa Code section 85.36(___).
The rate of weekly compensation is $______________. (If the rate for PPD
differs it is $_______________ per week.)
4. The injury caused Claimant to sustain the following disability and resulting
entitlement to compensation:
a. Temporary total disability/temporary partial disability/healing period
compensation for __________ weeks from __________
thru
(date)
___________
Iowa Code sections 85.33, 85.34(1).
(date).
(A detailed
description may be attached.)
b. Permanent partial disability for ____ % loss of _________________
resulting in ______ weeks of compensation
(member or earning capacity)
under Iowa Code Section 85.34(2)(___) payable commencing
________________
(date).
c. Other compensation or benefits consisting of _______________
_____________________________________________________
_____________________________________________________
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