Form 14-0025 - Compromise Settlement - Iowa Workers' Compensation Commissioner (Page 2 of 2) in pdf

Form 14-0025 - Compromise Settlement - Iowa Workers' Compensation Commissioner Page 2

approves this compromise settlement and the employer/insurance carrier pays me the

agreed sum, then I am barred from future claims or benefits under the Iowa Workers'

Compensation Law for the injury(ies) compromised. I understand I may: 1) consult

with an attorney of my own choosing, or 2) call the Iowa Division of Workers’

Compensation at (515) 281-5387, or both in order to receive a full explanation of the

terms of this document and of my rights under the Iowa Workers' Compensation Law.

I have either done so or freely waive my right to do so.

_________________________________

________________________________

Claimant's Attorney

Date

Claimant

Date

Subscribed and sworn to by claimant before me on this ________ day of

______________________________, _______.

___________________________________________

Notary Public

Employer/Insurance Carrier: The employer/insurance carrier consents to the

compromise settlement.

___________________________________________________________

Employer/Insurance Carrier’s Attorney

Date

___________________________________________________________

Employer/Insurance Carrier

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).

14-0025 (7/05)

Form 14-0025 - Compromise Settlement - Iowa Workers' Compensation Commissioner Page 2