Fill and Sign the Original Notice Ampamp Petition Iowa Division of Workers Form

BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER ORIGINAL NOTICE AND PETITION FILE NUMBER_________________________________ FORM NO. 100 -- (14- 0005) 11-06 (SEE INSTRUCTIONS ON REVERSE SIDE) Claimant vs. Employer Insurance Car rier Arbitration (86.14) Dependency (85.42, 43, 44) Review -Reopening (86.14) Equitable Apportionment (85.43) Medical Benefits Second Injury Fund r (85.27 Benefits) r (85.63 et seq.) Death Benefits Other (attach petition) r (85.28, 29 31) You are notified that an action has been commenced before the Workers’ Compensation Commissioner seeking relief under the Chapter s 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 judic ial 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 provide d will be open for public inspection under Iowa Code §22.11 IF ADDITIONAL SPACE IS NEEDED, USE REVERSE SIDE; IDENTIFY BY BOX NUMBER 1. Employer’s Address 2. Ins. Co. Address ________________________ ______________________________ _ _________________________________________________________ Street Street ___________________________________________ ____________ _________________________________________________________ City State .Zip City State .Zip 3 . Inj. Date (s)__________________________________________________________________________________________________________________________ 4. How did injury occur? ___________________ _______________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ______ 5 . Part s of body affected or disabled ________________________________________________________________________________________________________ 6. Have voluntary weekly payments been made? Yes ________________________ No _______________________ 7 . Time disabled (give dates) ___________________________________________________________________________________________________________ __ 8 . Nature and extent of perman ent disability: ______________________________________________________________________________________________ 9 . 85.27 expenses: With whom incurred and amount :_________________________________________________________________________________________ 1 0. State the dispute in this case : _______________________________________________________________________________________________________________________________ 11. County and judicial district where injury occurred (or Polk county if out 12. Petitioner requests respondent to agree hearing may be held in the following of state) judicial district _______________________________________________________ _____________________________________ __________________________ 13. If second injury fund benefits a. date of first loss _______________ b. member affected (first loss) _______________ ____ c. how affected _______________ __ DEATH : 14. Deceased Name________________________________ 15. Relationship to Claimant __________________ 16 . Date of Death___________ ________ 17. Funeral Expense: $_______________________ 18 . Dependents (state relationship):a.____________________________ b.____________________________ The petitioner inc orporates by this reference the statutory provisions applicable to the relief sought and prays the Workers’ Compensation Comm issioner grant the relief sought, set a time and place for the hearing and request the respondents to respond or incur the sanctio ns noted above. ___________________________________________________________ _________________________________________ _____________________ ____ Petitioner’s Attorney (Please Print) Signature (of attorney, or petitioner if unrepresented) Date ___________________________________________________________ __________________ _______________________ ______________ _____ ______ Address of Attorney Fax Number of Attorney Phone of Attorney ___________________________________________________________ _________________________________________ Email address of Attorney Phone of Petitioner 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 $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 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 fr ont of this form. Please indicate the box number that requires the additional information. TYPE OR PRINT LEGIBLY. 14-0005 Backer (11-06)