Fill and Sign the Contested Case File No Form

BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER ________________________________________________________________ : _____________________________ : Cla imant, : Con tested 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. C laimant sustained an injury ar ising out of and in the course of employment with Employer on _____________ __________ (date) . 2. Jurisdiction exists because t he injury occurr ed 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 cause d 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 f or ____ % loss of _________________ (member or earning capacity) resulting in ______ weeks of compensation under Iowa Code Section 85.34(2)(___) payable commencing ________________ (date) . c. Other compensation or benefits consisting of _______________ ___________________________________ __________________ ___________________________________ __________________ 5. Benefits that accrued and were paid are shown in the attached payment activity report (PAR), dated ___________ ___________. B enefits that remain to be paid are ______________________ _ ________________________ ___________________________ 6. The employer/insurance carrier sha ll file a final electronic Subsequent Report of Injury [SROI (FN)] and mail C laimant 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 settlemen t 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 e ntitled to medi cal 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 attach ed 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 waiv es 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 t herefore a pproved 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)