BEFORE THE IOWA WORKERS' COMPENSATION COMMISSIONER _____________________________________________________________________ : _____________________________ : Claimant, : Contested Case File No.:____________ : vs. : Compliance File No.: _______________ : ____________________________ : Injury Date: ______________________ Employer, : : and : COMBINATION SETTLEMENT : [Iowa Code Section 85.35(4)] ____________________________ : Insurance Carrier, : Defendants. : _____________________________________________________________________ The undersigned parties submit this Combination Settlement to the Workers' Compensation Commissioner pursuant to Iowa Code section 85.35(4). In support of it, these parties agree: 1. The claimant sustained an injury that arose out of and in the course of the employment on _____________________ (date of injury). 2. The employer/insurance carrier is compensating claimant for the disability described in the accompanying Agreement for Settlement without dispute. 3. The employer/insurance carrier disputes other claims made by claimant that claimant attributes to the employer, and the parties are making a full and final disposition of all other such injuries, disabilities, or claims as set forth in the accompanying Compromise Settlement. _________________________________ _________________________________ Claimant Date Employer/Insurance Carrier Date _________________________________ __________________________________ Claimant's Attorney Date Employer/Carrier's Attorney Date Approved as part of the accompanying settlements 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). 14-0159 (02/15) American LegalNet, Inc. www.FormsWorkFlow.com