Fill and Sign the Combination Settlement Form

BEFORE THE IOWA WORK ERS’ 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. T he 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 fina l 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 settleme nts 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 )