Form 14-0025 - Compromise Settlement - Iowa Workers' Compensation Commissioner printable pdf download

Form 14-0025 - Compromise Settlement - Iowa Workers' Compensation Commissioner

BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER

____________________________________________________________________________

_____________________________

Claimant,

Contested Case File No.: _________________

vs.

Compliance File No.: ___________________

____________________________

Injury Date: ______________________

Employer,

and

COMPROMISE SETTLEMENT

[Iowa Code Section 85.35(3)]

____________________________

Insurance Carrier,

Defendants.

____________________________________________________________________________

The undersigned parties submit this Compromise Settlement pursuant to Iowa Code

section 85.35(3).

A. A dispute exists under the Iowa Workers’ Compensation Law, which the parties seek to

resolve by a full and final compromise disposition of claimant’s claim for benefits. The

subject and nature of the dispute is _____________________________________

_____________________________________________________________________

B. If claimant is not represented by an attorney; a claimant’s statement and evidence of the

dispute is attached. Rule 876 IAC 6.1.

C. As a compromise of their competing interests, the parties agree to the payment and other

terms of settlement contained in the attached page(s) or as follows:.

Release: In consideration of this payment, claimant releases and discharges the

above employer and insurance carrier from all liability under the Iowa Workers'

Compensation Law for the above compromised claim.

Statement of Awareness of Claimant: I have read the compromise settlement and

attached page(s). I understand that the money I receive under this settlement is the

total amount I will receive from my claim and that there will not be a hearing and

decision on my claim. I am aware that if the Workers’ Compensation Commissioner

Form 14-0025 - Compromise Settlement - Iowa Workers' Compensation Commissioner