Form 14-0025 - Contested Case Settlement printable pdf download

Form 14-0025 - Contested Case Settlement

BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER

____________________________________________________________________________

____________________________

File No(s): ___________________________

Claimant

S.S. No(s): ___________________________

vs.

Injury Date(s):__________________________

____________________________

Employer

CONTESTED CASE SETTLEMENT

and

(Section 85.35, Iowa Code)

____________________________

Insurance Carrier

____________________________________________________________________________

The undersigned parties make application for authorization and approval of a

CONTESTED CASE SETTLEMENT pursuant to section 85.35, Iowa Code.

A Bona Fide Dispute exists under Iowa Code subsections 85.35(1), (2), (3), (4), (5), (6),

(7), (8). (Circle applicable subsection(s).) Attach evidence of bona fide dispute.

Payment Terms: (Attach additional page if necessary)

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 injury.

Statement of Awareness of Claimant: I have read the contested case settlement and

attachments and am aware upon receipt of the payment and approval by the Workers’

Form 14-0025 - Contested Case Settlement