Form 100 - Original Notice And Petition Before The Iowa Workers' Compensation Commissioner - 2004 Page 2

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INSTRUCTIONS
1. All boxes and blanks appropriate to your claim must be checked and completed. All addresses must be
given. You or your attorney must sign where indicated. PLEASE TYPE OR PRINT LEGIBLY.
2. This form with the original signature is to be filed with the Workers’ Compensation Commissioner.
3. Delivery of a copy of this form to the employer is to be by certified mail, return receipt requested or by
personal service as in civil actions, rule 876 - 4.7.
4. A copy of this form, with proof of delivery, must be filed with the Workers’ Compensation Commissioner.
Rule 876 4.7
5. On or after July 1, 1988, for all original notices and petitions for arbitration or review-reopening seeking
weekly benefits filed on account of each injury, gradual injury, occupational disease or occupational
hearing loss alleged by an employee, a filing fee of $65 shall be paid at the time of filing.
6. A separate petition shall be filed for each occurrence of claimed injury, occupational disease or occupa-
tional hearing loss and the petition must allege a specific day, month, and year of each occurrence. See
rule 876 1AC 4.6 regarding pleading alternative or multiple dates of occurrence and joinder.
7. See rule 876 - 4.8 for further information.
The following space is to be used for additional information for which inadequate space exists on
the front of this form. Please indicate the box number that requires the additional information.
TYPE OR PRINT LEGIBLY.
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