BEFORE THE IOWA WORKERS' COMPENSATION COMMISSIONER ________________________________________________________________ : _____________________________ : Claimant, : Contested Case File No.___________ : vs. : Compliance File No._______________ : ____________________________ : Injury Date: _________________ Employer, : : and : AGREEMENT FOR SETTLEMENT : Iowa Code Section 85.35(2) ____________________________ : Insurance Carrier, : Defendants. : ________________________________________________________________ The undersigned parties submit this Agreement for Settlement to the Workers' Compensation Commissioner for approval. The parties agree: 1. Claimant sustained an injury arising out of and in the course of employment with Employer on _______________________ (date). 2. Jurisdiction exists because the injury occurred in Iowa OR Iowa Code section 85.71(___) applies. (Circle one.) 3. Claimant is married/single (circle one), entitled to ____exemption(s) and gross weekly earnings are $___________ using Iowa Code section 85.36(___). The rate of weekly compensation is $______________. (If the rate for PPD differs it is $_______________ per week.) 4. The injury caused Claimant to sustain the following disability and resulting entitlement to compensation: a. Temporary total disability/temporary partial disability/healing period compensation for __________ weeks from __________ (date) thru ___________ (date). Iowa Code sections 85.33, 85.34(1). (A detailed description may be attached.) b. Permanent partial disability for ____ % loss of _________________ resulting in ______ weeks of compensation under Iowa Code Section 85.34(2)(___) payable commencing ________________ (date). c. Other compensation or benefits consisting of _______________ _____________________________________________________ _____________________________________________________ (member or earning capacity) American LegalNet, Inc. www.FormsWorkFlow.com 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 (02/15) American LegalNet, Inc. www.FormsWorkFlow.com