Iowa > Workers Compensation
Agreement For Settlement 14-0021 - Iowa
| Agreement For Settlement Form. This is a Iowa form and can be used in Workers Compensation . |
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BEFORE THE IOWA WORKERS COMPENSATION COMMISSIONER_________________________________________________________________________ : : ____________________________ : Claimant : File No.:__________________ : vs. : S.S. No.:_________________ : ____________________________ : Injury Date:_______________ Employer : : and : AGREEMENT FOR SETTLEMENT : (Section 86.13, Iowa Code)____________________________ : Insurance Carrier : _________________________________________________________________________ COME NOW claimant, employer/insurance carrier and submit thisAGREEMENT FOR SETTLEMENT to the Workers Compensation Commissioner pursuantto Iowa Code section 86.13. In support thereof, the parties state: 1. The parties agree that the claimants accrued and paid entitlement toworkers compensation for the injury arising out of and in the course of his/heremployment on _______________________is set out in the claim activity report (date of injury) form 2 or 2A, dated _____________________, attached hereto and incorporated (date of form) as if set out in full. 2. The parties agree that claimant: (Choose one) ________is entitled to an additional _____________ weeks of benefits totaling $________________ paid as they accrue. ________is not entitled to additional weekly benefits. ________all benefits have accrued and will be paid in a lump sum.<<<<<<<<<********>>>>>>>>>>>>> 2 3. The parties agree that as a result of the injury claimant is entitled topermanent partial disability benefits equal to ________% of the __________________. (scheduled member/baw)This disability is supported by the medical records attached hereto and submitted in supportof this Agreement for Settlement . 4. The employer/insurance carrier shall file with the Workers CompensationCommissioner and mail to the claimant a final report form 2A indicating the date of lastpayment. Rules 876 IAC 2.6 and 3.1. 5. The parties agree that the claimants right to review-reopening will be available tothe claimant for three years following the last date of payment of weekly disability benefitsand that the claimant remains entitled to medical treatment for authorized care causallyconnected to the injury pursuant to Iowa Code section 85.27. WHEREFORE, the parties respectfully request the Workers CompensationCommissioner approve this Agreement for Settlement ._________________________________ Claimant Date _________________________________ __________________________________Claimants Attorney Date Employer/Insurance Carrier DateAPPROVED this _________________ day of_____________________________ ______________________________________ Iowa Workers Compensation CommissionerThe information provided will be open for public inspection under Iowa Code 22.11.14-0021 (7/99)
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