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Notice and Petition Iowa Division of Workers

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ORIGINAL NOTICE AND PETITION

FORM NO. 100 -- (14-0005) 07-09

BEFORE THE IOWA WORKERS' COMPENSATION COMMISSIONER

(SEE INSTRUCTIONS ON REVERSE SIDE)

vs.

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. 12 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 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

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.

INSTRUCTIONS

1. All boxes and blanks appropriate to your claim must be checked and completed. All addresses must be given. Attach a copy of the Claimant's Confidential Statement (form 14-0171). 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 $100 shall be paid at the time of filing.

6. A separate petition shall be filed for each occurrence of claimed injury, occupational disease or occupational hearing loss and the petition must allege a specific day, month, and year of each occurrence. See rule 876 IAC 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.

14-0005 Backer (07-09)

IOWA.

WORKFORCE

DEVELOPMENT

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What the Notice and Petition to the Iowa Division of Workers' Compensation Is

A Notice and Petition filed with the Iowa Division of Workers' Compensation begins the formal administrative process when an injured worker seeks benefits or a hearing. The document identifies the claimant, employer, insurer, date and nature of injury, medical treatment received, and the specific relief requested. Filing creates a docketed claim and typically triggers employer and insurer responses and potential scheduling for mediation or hearing. Many filers submit this form electronically; procedural rules and evidence requirements are set by the Division and relevant state statute.

Why filing a Notice and Petition matters

Filing preserves legal rights, begins adjudication, and creates a record for benefits and medical expense recovery under Iowa workers' compensation rules.

Why filing a Notice and Petition matters

Who prepares and responds to a Notice and Petition

Typical filers and responding parties include employers, claimants, insurers, and legal representatives working within the workers' compensation system.

  • Injured employees or claimants seeking medical benefits, wage replacement, or vocational assistance following a work-related injury or occupational disease.
  • Employers and human resources professionals who must respond, report claim information, and coordinate defense or accommodation measures.
  • Insurers and claims adjusters who handle indemnity, medical payment, investigative steps, and interlocutory filings to protect their interests.

Step-by-step: completing a Notice and Petition

Follow these sequential steps to prepare a complete Notice and Petition for the Iowa Division of Workers' Compensation.

  • 01
    Gather Details: Collect claimant, employer, insurer, and injury information.
  • 02
    Complete Form: Enter factual responses and relief sought accurately.
  • 03
    Attach Evidence: Include medical reports, wage records, and employer notices.
  • 04
    File & Serve: Submit to the Division and serve opposing parties per rules.

Essential data elements required on the form

Claimant SSN: Last four digits acceptable
Date of Injury: MM/DD/YYYY
Employer ID: FEIN or business name
Insurer Name: Carrier handling claim
Medical Provider: Primary treating clinician
Relief Type: Medical, wage, or other

Penalties and risks of incorrect or late filings

Procedural Dismissal: Case may be dismissed
Delayed Benefits: Payments can be postponed
Evidence Gaps: Missing records weaken claims
Sanctions: Court may impose costs
Forfeiture: Rights to certain relief lost
Appeal Exposure: Adverse rulings become final

Common mistakes to avoid when preparing the petition

  • Providing an incomplete injury date or vague chronology, which complicates statute of limitations and coverage analysis.
  • Failing to attach key medical or wage evidence, creating avoidable records disputes at hearing.
  • Using inconsistent party names or addresses, which leads to failed service and procedural delays.
  • Neglecting to specify the relief requested, causing ambiguous claims and requiring corrective filings.

How filing and processing typically proceeds

This high-level flow shows how the Division receives, routes, and advances a Notice and Petition toward resolution.

  • Upload: File the form with the Division clerk.
  • Serve: Deliver copies to employer and insurer.
  • Response: Employer or insurer files an answer or defense.
  • Scheduling: Mediation or hearing is set by the Division.

Digital workflow settings for online completion

Recommended workflow options when filing a Notice and Petition electronically to ensure authentication and recordkeeping.

Field Configuration
Authentication Email link or SMS code
Signer Order Claimant first, then employer
File Format PDF/A or flattened PDF
Retention Permanent copy and audit trail

Technical options for e-submission and integrations

Ensure the platform you use produces a tamper-evident copy, stores an audit trail, and meets any Division authentication requirements before filing.

  • PDF Support: PDF, DOCX accepted
  • Integrations: Salesforce, Microsoft 365
  • Storage: Box, Google Drive

Timing considerations and typical administrative deadlines

Timelines vary by fact pattern and statutory rules; file as soon as practicable and confirm deadlines with the Division.

Initial Filing:

File promptly after injury; delays risk forfeiture

Employer Notice:

Report claim to insurer per company policy

Medical Records:

Submit contemporaneous treatment notes with petition

Mediation Window:

Division may offer early mediation scheduling

Hearing Dates:

Hearing scheduled after pleadings and discovery

Key milestones from injury to resolution

A typical sequence outlines key milestones and actions from the incident through final determination.

01

Injury Occurs

Immediate medical evaluation and employer notification.

02

File Petition

Submit Notice and Petition with supporting records.

03

Responding Pleadings

Employer or insurer files an answer or defenses.

04

Adjudication

Mediation or hearing leads to decision and potential appeal.

How a Notice and Petition differs from related documents

Compare this formal filing to other common documents used in workers' compensation matters.

Document Type Purpose File With
Notice and Petition begin claim adjudication division
Informal Claim initial notice only employer/insurer
IMEs and Requests medical evaluation requests medical providers
Settlement Petition request approval of negotiated settlement division

Sample eSignature provider comparison for filing and serving forms

These pricing and capability rows give a high-level vendor comparison for eSignature services commonly used to prepare and submit forms to administrative agencies.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Typical signers and their roles

Claimant — Worker

An individual who was injured or exposed at work and files the petition to seek medical treatment, wage-loss benefits, or vocational services through the Division.

Employer — Representative

A human resources or management designee who reviews allegations, coordinates with insurer, and responds to the petition on behalf of the employing entity.

Real-world examples of digital filing and outcomes

Two brief examples show how electronic filing and clear petitions can streamline processing and documentation.

Martin Properties (Claim Filing)

A property manager filed a timely petition with full medical attachments to avoid delay.

  • The employer responded with coverage details.
  • "I can process and execute all of these documents online with 100% compliance and built-in security. Whether on mobile or working offline, I can get forms back to their necessary parties efficiently."

Optica Ventures (Administrative Efficiency)

A small employer digitized its claim intake to reduce errors and speed responses.

  • The insurer accepted electronic evidence.
  • "The interface is simple and easy-to-use for our team; more importantly, it is just as easy for our customers."

Practical tips for accurate and efficient filings

Adopt these practical measures to minimize delays, avoid re-filing, and preserve evidentiary clarity.

Complete All Required Fields
Fill every mandatory field, using exact legal names and MM/DD/YYYY dates to avoid processing errors and returned filings.
Attach Supporting Evidence
Include contemporaneous medical records and wage documentation to substantiate claims and speed initial review.
Use Secure eSignature
Choose a platform with audit trails and encryption to authenticate signers and protect personal data during transmission.
Confirm Service
Document how you served employer and insurer—certified mail, email with delivery receipt, or platform-based service logs.

Frequently asked questions about filing a Notice and Petition

Answers to common procedural and technical questions when preparing or submitting a petition to the Division.


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