Adobe Acrobat Reader
You must use Adobe Acrobat Reader to complete Iowa Division of Workers' Compensation (DWC) forms electronically. Other PDF readers might not render the forms correctly. To get Adobe Acrobat Reader for free, click here.
You must use this form for a compromise settlement under Iowa Code section 85.35(3).
Failure to use this form may result in the DWC rejecting your settlement documents.
- 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.
- Complete the caption by providing in the corresponding blank the:
- Name of the claimant.
- Name of the employer.
- Name of any insurance carrier. Note: In some cases, there is not an insurance carrier (e.g., when the employer is self-insured) or any other defendants.
- Name(s) of any other defendant(s).
- Agency file number(s). Note: If you are settling a combined case, which consists of more than one agency file number, you must list all agency file numbers on the form.
- Complete the form by filling out paragraphs 1 and 2.
- The parties and their attorneys sign the form. The claimant's signature must be notarized.
- File the completed form with the DWC. Note: If you are settling a combined case, which consists of more than one file number, you must electronically file (eFile) the completed form on the Workers' Compensation Electronic System (WCES) under each file number.
DWC Approval of Settlement Documents
DWC must approve settlements of workers' compensation claims. For more information, click here.
eFiling on WCES
DWC requires the electronic filing (eFiling) of settlement documents, such as this completed form, on the Workers' Compensation Electronic System (WCES).
For more information about eFiling, click here.
efiling Tips: Settlement Documents
DWC has developed tips for eFiling settlement documents on WCES. To view the tips for eFiling settlement documents on WCES, click here.