Agreement For Settlement Form - Iowa Workers' Compensation Commissioner (Page 2 of 2) in pdf

Agreement For Settlement Form - Iowa Workers' Compensation Commissioner Page 2

5. Benefits that accrued and were paid are shown in the attached

payment activity report (PAR), dated ______________________.

Benefits that remain to be paid are _______________________

___________________________________________________

6. The employer/insurance carrier shall file a final electronic Subsequent

Report of Injury [SROI (FN)] and mail Claimant a PAR that contains the

information in the final SROI, including the date that weekly

compensation was last paid. Rules 876 IAC 2.6, 3.1(2), and 11.7.

7. This settlement waives a hearing, decision, and resulting statutory benefits. It

is subject to review-reopening for three years following the last date that

weekly compensation is paid. Iowa Code sections 85.26(2) and 86.14.

8. Claimant is entitled to medical care for the injury, including care in the future.

Iowa Code sections 85.26(2) and 85.27.

(A detailed description may be attached.)

9. Evidence that corroborates this settlement is attached. A

Claimant’s

Statement

is attached if claimant is not represented by an attorney.

WHEREFORE, the parties request that this Settlement be approved.

__________________________________ _____________________________

Claimant

Date

Claimant’s Attorney

Date

__________________________________ _____________________________

Employer/Insurer

Date

Employer/Insurer’s Attorney

Date

ORDER

I find that substantial evidence supports the terms of the foregoing settlement,

the employee knowingly waives hearing, decision, and resulting statutory

benefits and the settlement is a reasonable and informed compromise of the

competing interests of the parties. The foregoing settlement is therefore

approved this ____ day of_____________________, 20____.

______________________________________

Iowa Workers’ Compensation Commissioner

The information provided will be open for public inspection under Iowa Code §§

22.11 and 86.45(1).

14-0021 (7-05)

Agreement For Settlement Form - Iowa Workers' Compensation Commissioner Page 2