CHECKLIST
SPECIAL CASE SETTLEMENT (IOWA CODE SECTION 85.35)
THIS FORM MUST ACCOMPANY THE SETTLEMENT DOCUMENTS
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All documents must be legible.
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One set of papers for each date of injury.
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8 1/2 x 11 white papers (all documents).
876 IAC 4.16
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Originals and copies clearly identified.
876 IAC 4.16
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Self-addressed stamped envelope (adequate size with sufficient
postage).
876 IAC 4.16
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First report of injury must be filed for each date of injury (if
appropriate).
Iowa Code section 86.11
876 IAC 3.1(6)
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Final, updated claim activity report must be filled out in its
entirety and filed with the settlement papers.
876 IAC 3.1(2) and (3)
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Clearly identify, by highlighting, the evidence of a bona fide
dispute in the records attached to the form.
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Not more than 20 pages of medical records shall be submitted
with the settlement documents.
876 IAC 6.1
PREPARED BY:_____________________
DATE:_________________
print or type
TELEPHONE NUMBER: (
) ________________
14-0027 (7-99)