Agreement For Settlement Form 1999 printable pdf download

Agreement For Settlement Form 1999

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 this

AGREEMENT FOR SETTLEMENT to the Workers’ Compensation Commissioner pursuant

to Iowa Code section 86.13. In support thereof, the parties state:

1. The parties agree that the claimant's accrued and paid entitlement to

workers’ compensation for the injury arising out of and in the course of his/her

employment 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.

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.

Agreement For Settlement Form 1999