Fill and Sign the Form 9a 309 5019 4 96before the Iowa Industrial Commissionerfile No

FORM 9A - 14 -0017 ( 02/15 ) BEFORE THE IOW A W ORKERS’ COMPENSATION COMMISSIONER File No. ___________ ______________________________________________ __________________ Compliance File No. ____________ Claimant VS. (Injury Date) ORIGINAL NOTICE AND PETITION _______________________ _______________________ AND ORDER Employer FOR PARTIAL COMMUTATION _________ _____________________________________ Insurance Carrier To Employer and Insurance carrier: You are notified that an action for partial commutation has been commenced before the work ers’ compensation commissioner seeking relief under the chapters of the Io wa Code relating to workers' compensation, occupational disease and occupational hearing loss (Chapter 85, 85A, 85B, 86 and 87). A hearing will be held in the judicial district wherein the injury occurred. When a pplicable, the parties will be notified by the workers’ compensation commissioner of the time and place of the prehearing conference and hearing. 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 IAC 4.9. Fai lure to comply may result in the imposition of the sanctions of 876 IAC 4.36. Payment Activity Report (PAR) shall match calculation below. A. The undersigned makes Application for Partial Commutation of remaining benefits in the above entitled case and re presents: 1. As a result of the compensable injury or death, claimant has suffered a permanent disability equal to _______ % of the ____ ________ 2. Total Entitlement ................... Temporary Partial Healing Period Permanent/Death Weeks ________________ Weeks _______________ Weeks _______________ $ _________ ___________ $ ___________________ Amount Paid ________________ Rate _________________ Rate ________________ $ _______________ Total 3. Paid to Date .......................... Temporary Partial Healing Period Permanent/Death Weeks ________________ Weeks ________________ Weeks ______________ $ _____________________ $ ___________________ Amount Paid _____ ___________ Thru ___________________ Thru _________________ $ _______________ Date Date Total 4. Accrued -Not Paid ................... Temporary/Partial Healing Per iod Permanent/Death Weeks ________________ Weeks _________________ Weeks _______________ $ ______________________ $ ____________________ Amount Paid ________________ Thru ____________________ Thru _________________ $ ______________ __ Date Date Total 5. Remainder .............................................. _____________________ Weeks @ $ ___________________ Total $ _______________ 6. Commutat ion of _________________ Weeks for First p art of remaining period Last part of remaining period Pro Rata 7. Commuted Value .................................... _____________________ X ____________________________ = $ ____________________ Factor Weekly Rate Commuted Value 8 Remainder After Commutation (if approved) _____________________ Weeks @ $ __________________ = $ ____________________ Total 9. Other Terms ________________________________________________________________________________________________________________ B. Attach pertinent, legible medical records not exceeding 20 pages indicating: (1) The degree of disability (2) The condition is not e xpected to deteriorate (3) The condition is not expected to require future treatment (unless provision has been made for future treatment) C. Statement of Need in dollars and cents. I will use the funds for the following: 1. __________________________ _________________________________________________________ $ _________________ 2. __________________________________________________________________________________ __ $ _________________ 3. ________________________________________________________________ __________________ __ $ _________________ 4. __________________________________________________________________________________ __ $ _________________ Attorney fee disclosure: $______________________________ = _____ % of settlement D. I am the person entitled to workers' compensation benefits on account of the indicated injury or death. I have read the foregoing and all at tachments. I consent to the degree of disability and the granting of the commutation. In the event the employer consents to the comm utation, I waive any provision concerning contested cases as provided in Chapter 17A or otherwise. If I am not represented, I waive my right to an attorney ____________________________________________________________ ____________________________________________________________ Claimant’s Attorney Date Claimant Date _____________________________________________________________ ____________________________________________________________ Email Address of Attorney Fax Number of Attorney E. EMPLOYER 1. The employer/insurance carrier consents to the degree of disability and the granting of the commutat ion and waives any provision concerning contested cases as provided in Chapter 17A or otherwise. ______________________________________________________________ Employer/Insurance Carr ier ______________________________________ _____________ ______________________________________________________ Email Address of Attorney Fax Number of Attorney 2. The employer/insurance carrier resists the relief sought in the petition for commutation but acknowledges delivery of a copy of the original notice and petition. (Check one)  A hearing is waived  A hearing is requested  For Partial Commutations filed after June 30, 2017, the petition will be dismissed if the employer/insurer do not consent and check this box. _________________________________ __________________________ Employer/Insurance Carrier Date _________________________________________________________ __________________________________________________________ Email Address of Attorney Fax Number of Attorney The foregoing Application for Commutation is approved and the relief sought is granted ________________________ , _______ . ___________________________________________________ Iowa W orkers’ Compensation Commissioner NOTICE TO APPLICANT DELIVERY OF FORM 1. Delivery of this form is to be by personal service as in civil actions or by certified mail, return receipt requested. Rule 876 IAC 4.7. 2. A copy of this form with proof of delivery and claimant’s confidential statement must be filed with the Division of W orkers’ Compensation no later than 10 days after delivery upon the respondent. Rule 876 IAC 4.8. 3. The Commissioner will not deliver this form to the respondent for a petitioner. DIVISION OF WORKERS’ COMPENSATION, 1000 EAST GRAND AVENUE, DES MOINES, IOWA 50319 -0209 (515) 281 -5387 The information provided will be open for public inspection under Iowa Code §§ 22.11 and 86.45(1) 14 -0017 BACK ( 07/17 )