Form 100 - Original Notice And Petition Before The Iowa Workers' Compensation Commissioner - 2004

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BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER

FILE NUMBER

ORIGINAL NOTICE AND PETITION

FORM NO. 100 -- (14-0005) 12-04

CLAIMANT’S SOCIAL

SECURITY NUMBER

(SEE INSTRUCTIONS ON REVERSE SIDE)

Arbitration (86.14)

Dependency

Claimant

(85.42, 43, 44)

Reviewing-Reopening

vs.

(86.14)

Equitable Apportionment (85.43)

Second Injury Fund

Medical Benefits

Employer

(85.63 et seq.)

(85.27 Benefits)

Other (attach petition)

Death Benefits

Insurance Carrier

(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 document or to

otherwise move or respond as provided by rule 876-4.9 of the Workers’ Compensation 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 BOX NUMBER

2. Employer’s Address

3. Ins. Co. Address

1. Claimant’s Address

Street

City

State

Zip

City

State

Zip

City

State

Zip

6. Relationship of claimant

4. Inj. Date(s)

5. Deceased Name

7. Other Dependents

(state relationship):

8. Date of Death

9. Funeral Expense

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 permanent 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 of state) 18.

Petitioner requests respondent to agree hearing may be held in the following

judicial district

19.

If second injury fund benefits a. date of first loss _________________ b. member affected (first loss _________________ c. how effected _________________

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 (Please Print)

Phone of Attorney

Signature (of attorney, or petitioner if unrepresented)

Date

Address of Attorney

Phone of Petitioner