Checklist Agreement For Settlement Form

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CHECKLIST
AGREEMENT FOR SETTLEMENT
THIS FORM MUST ACCOMPANY THE SETTLEMENT PAPERS
________
All documents must be legible.
________
One set of papers is required for each date of injury.
________
8 1/2 x 11 white paper (all documents).
876 IAC 8.7
________
Originals and copies must be clearly identified.
876 IAC 4.16
________
Self-addressed stamped envelope (adequate size with sufficient
postage).
876 IAC 4.16
________
First Report of Injury must be filed for each date of injury.
Iowa Code section 86.11; 876 IAC 3.1(1)
________
Current payment activity report for each date of injury must be
filled out in its entirety and filed with the settlement.
876 IAC 3.1(2) and (3)
PREPARED BY:________________________
DATE_____________________
print or type
TELEPHONE NUMBER:___________________
14-0023 (7-05)

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