Checklist For Compromise Settlement Form
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1CHECKLIST
COMPROMISE SETTLEMENT (IOWA CODE SECTION 85.35)
THIS FORM MUST ACCOMPANY THE SETTLEMENT DOCUMENTS
________
All documents must be legible.
________
One set of papers for each date of injury.
________
8 1/2 x 11 white papers (all documents).
876 IAC 4.16
________
Originals and copies 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 (if
appropriate).
Iowa Code section 86.11
876 IAC 3.1(6)
________
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)
PREPARED BY:_____________________
print or type
DATE:__________________________
TELEPHONE NUMBER:________________
14-0027 (7-05)
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