Form 14-0025 - Contested Case Settlement (Page 2 of 2) in pdf

Form 14-0025 - Contested Case Settlement Page 2

Compensation Commissioner I am barred from future claims or benefits under the Iowa

Workers' Compensation Law for the injury(ies) and the payment shall not be construed

as payment of weekly compensation. I understand I have the rights to 1) consult with an

attorney of my own choosing and 2) to call the office of the Workers’ Compensation

Commissioner at (515) 281-5387 for a full explanation of the terms of this document and

my rights under the Iowa Workers' Compensation Laws, and that I have either exercised

the rights or wish not to do so.

___________________________________

__________________________________

Claimant's Attorney

Date

Claimant

Date

Subscribed and sworn to by claimant before me on this ________ day of

______________________________, _______.

______________________________________

Notary Public

Employer/Insurance Carrier: The employer/insurance carrier consents to the contested

case settlement.

______________________________________

Employer/Insurance Carrier

Date

Approval: The contested case settlement is approved on this _______ day of

_______________________________, _________.

______________________________________

Iowa Workers’ Compensation Commissioner

The information provided will be open for public inspection under Iowa Code §22.11.

14-0025 (7/99)

Form 14-0025 - Contested Case Settlement Page 2