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:. D. 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 approves this compromise settlement and the employer/insurance carrier pays me E. American LegalNet, Inc. www.FormsWorkFlow.com 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 (02/15) American LegalNet, Inc. www.FormsWorkFlow.com