Agreement for Settlement — Form 14-0021

Description: 

Effective July 22, 2019

Submission of Settlement Documents

The Iowa Division of Workers' Compensation (DWC) implemented mandatory electronic filing (eFiling) in contested cases via the Workers' Compensation Electronic System (WCES) effective July 22, 2019.  The DWC has changed some of its forms due to the transition to WCES.  Parties are encouraged to use the new settlement forms immediately.  However, the agency will continue to accept settlements on the “old” forms through August 30, 2019.  The “old” forms shall be submitted via WCES as proposed settlement forms.  Effective September 1, 2019, the old settlement forms will not be accepted.    

Overview

This form is used to file an agreement for settlement with the Iowa Division of Workers' Compensation (DWC) under Iowa Code section 85.35(2).

The information provided will be open for public inspection under Iowa Code sections 22.1 and 86.45(1).

Adobe Acrobat Reader

You must use Adobe Acrobat Reader to complete DWC forms electronically. Other PDF readers might not render the forms correctly. To get Adobe Acrobat Reader for free, click here.

Instructions

  1. Download the form by clicking on the link above. Complete the form by typing the information into the fill-able fields on the PDF or by printing the form and handwriting in print the information on the printed form.
  2. Complete the caption by providing in the corresponding blank the:
    • Name of the claimant
    • Name of the employer
    • Name of any insurance carrier
    • Name(s) of any other defendant(s)
    • Any agency file number(s)

NOTE:  In some cases, there is not an insurance carrier (e.g., when the employer is self-insured) or any other defendant(s).

  1. Complete the form by filling out paragraphs 1 through 5.
  2. The parties and their attorneys sign the form.
  3. File the completed form with the DWC.

Mandatory eFiling

The DWC is implementing mandatory eFiling on the Workers' Compensation Electronic System (WCES) in contested case proceedings effective July 22, 2019.

You must eFile on WCES documents, such as this completed form, unless the DWC has granted you an eFiling exception.

For more information about eFiling, click here.