Fill and Sign the Iowa Workers Compensationfirst Report of Injury Form

BEFORE THE IOWA WORK ERS’ COMPENSATION COMMISSIONER _____________________________________________________________________ : _____________________________ : Claimant, : Contested Case File No.:____________ : vs. : Compliance File No.:_______________ : ____________________________ : Injury Date: ______________________ Employer, : : and : CONTINGENT SETTLEMENT : [Iowa Code Section 85.35(5)] ____________________________ : Insurance Carrier, : Defendants . : _____________________________________________________________________ The undersigned parties submit this Contingent Settlement to the Workers’ Compensation Commissioner pursuant to Iowa Code section 85.35(5) . These parties agree the accompanying settlement and its approval are conditioned upon the occurrence of the following event: _____________________________________________________________________ _____________________________________________________________________. If it appears that the contingent event will not occur within one year of the commissioner’s approval of this settlement, during the course of that year, a party may apply to the commissioner to vacate the settlement or extend the time allowed for the event to occur . If no party applies within the course of that year either to vacate the settlement or to extend the time allowed for the contingent event to occur, the contingency lapses and the settlement becomes final and fully enforceable. _________________________________ __________________________________ Claimant Date Employer/Insurance Carrier Date _________________________________ ___________________________________ Claimant’s Attorney Date Employer/Carrier’s Attorney Date Approved as part of the accompanying settlement 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 -0161 (02/15 )