Form No. 100 - 14-0005 - Original Notice And Petition
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1BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER
ORIGINAL NOTICE AND PETITION
FILE NUMBER___________________________________
FORM NO. 100 -- 14-0005 (11/00)
CLAIMANT’S SOCIAL
SECURITY NUMBER _____________________________
(SEE INSTRUCTIONS ON REVERSE SIDE)
Arbitration (86.14)
Dependency
Claimant
(85.42, 43, 44)
vs.
)
Review -Reopening (86.14
Equitable Apportionment (85.43)
Employer
Medical Benefits
Second Injury Fund
(85.27 Benefits)
(85.63 et seq.)
Insurance Carrier
Death Benefits
Other (attach petition)
(85.28, 29 31)
You are notified that an action has been commenced before the Workers’ Compensation Commissioner seeking relief under the Chapters of the
Iowa Code relating to workers’ compensation, occupational disease and occupational hearing loss (Chapters 85, 85A, 85B, 86, and 87). A hearing
will be held in the judicial district indicated in No. 17 below. You are required to file an answer within 20 days of the receipt of this docu
ment or to otherwise move or respond as provided by rule 876-4.9 of the Workers’ Compensation Commissioner’s Rules. Failure to comply may
result in the imposition of the sanctions of Workers’ Compensation Commissioner’s rule 876-4.36 such as barring you from further activity for failure
to appear and respond as required.
The information provided will be open for public inspection under Iowa Code §22.11
IF ADDITIONAL SPACE IS NEEDED, USE REVERSE SIDE; IDENTIFY BY BOX NUMBER
1. Claimant’s address:
2. Employer’s address:
3. Insurance Carrier's address:
_________________________________________________
__________________________________________________
____________________
___________________
Street
Street
Street
_________________________________________________
__________________________________________________
_______________________________________
City
State
Zip
City
State
Zip
City
State
Zip
4.
Injury date:
D
5. Deceased name:
6. Relationship of claimant:
7
. Other dependents (state relationship):
E
A
a._____________________________________
T
8. Date of death:
9. Funeral expense:
H
b. ____________________________________
10.
How did injury occur
?
11.
Parts of body affected or disabled:
12.
Have weekly payments been made?
a. Voluntary?____________b. Compensation?__________________
13.
Time disabled (give dates):
14. Nature and extent of p
ermanent disability:
15.
85.27 expenses (with whom incurred and amount):
a.__________________________________________________________________________________________________________________________________________
b.__________________________________________________________________________________________________________________________________________
16.
State the dispute in this case:
17.
County and judicial district where injury occurred (or Polk county if out
18.
Petitioner requests respondent to agree hearing may be held in the following
of state):
judicial district:
19.
If second injury fund benefits:
a. date of first loss________________
b. member affected (first loss)________________
c. how affected________________
The petitioner incorporates by this reference the statutory provisions applicable to the relief sought and prays the Workers’ Compensation Commissioner grant the
relief sought, set a time and place for the hearing and request the respondents to respond or incur the sanctions noted above.
____________________________________________________________________________________________________
Petitioner's Attorney
_____________________________________________________________________________________________________________________________________________
Address of Attorney
Phone of Attorney
Signature (of attorney, or petitioner if unrepresented)
Date
______________________________________
Phone of Petitioner
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