Fill and Sign the Original Notice and Petition for Voc Rehab Benefits Petition for Vocational Rehabilitation Benefits Form

14-0009 (11/06) (TYPE OR PRINT) FORM 100B BEFORE THE IOWA WORKERS' COMPENSATION COMMISSIONER Claimant_________________________________________ VS. Employer_________________________________________ Street____________________________________________ City_________________State______Zip_______________ Insurance Carrier __________________________________ Street____________________________________________ City_________________State______Zip________________ File Number_____________________________________ ORIGINAL NOTICE, PETITION, ANSWER AND ORDER CONCERNING VOCATIONAL REHABILITATION PROGRAM BENEFIT (Iowa Code Section 85.70) Injury Date_______________________________________ Body Part(s ) Injured________________________________ ORIGINAL NOTICE To the Above-Named Employer: You are notified that an action has been commenced before the Iowa Workers' Com pensation Commissioner seeking relief as set forth in the petition below. You are required to file and serve an answer to the petition (SEE REVERSE SIDE OF FORM) within 20 days following your receipt of this document or to otherwise move or respond as provided by Division of Workers' Compensation rules. Failure to comply may result in the imposition of sanctions under rule 876 IAC 4.36 and/or entry of a default and an award for the relief requested. NOTE: You should promptly advise your workers’ compensation insurance carrier and attorney that you have received this notice. PETITION (To Be Completed By Claimant and Vocational Rehabilitation Counselor) Claimant requests a vocational rehabilitation program benefit in acco rdance with Iowa Code section 85.70, as follows: Training Facility________________________________________________________________________\ ___________________________________________ NAME \ CITY STATE Type of Training________________________________________________________________\ __________________________________________________ Training will be for ____________weeks, commencing________________________________, ________. This training is part of a vocational rehabilitation program recognized by the State Board for Vocational Education. Completio n of the program will likely accomplish rehabilitation. Signature of Rehabilitation Counselor_________________________________________Date Si\ gned_______________________Phone ( ) ____________ ____ IN SUPPORT of this request claimant states: 1. Claimant sustained injury arising out of and in the course of employment with the employer on (Date)________________________ ___________ 2. The injury occurred at (City) ______________________________________ (County) __________________ (State)____________________ __ 3. Claimant has not returned to gainful employment and cannot do so because of permanent disability resulting from the injury as shown by the attached medical report. 4. Evidentiary hearing under Iowa Code section 17A.12 is waived. I, (Claimant's Signature) __________________________________________, Date Signe\ d____________________________________ certify, under penalty of perjury and pursuant to the laws of the Claimant's Phone No. State of Iowa, that the preceding petition is true and correct . (Include Area Code) _________________________________________ (If Represented by Attorney) Attorney__________________________________________________ \ __________________________________________ Street____________________________________________________ \ Signature of Attorney City__________________________State___________Zip__________ \ _________________________________________ _ Phone (Include Area Code)___________________________________ \ Email Address of Attorney Fax Number (Include Area Code) ______________________________ THE INFORMATION PROVIDED WILL BE OPEN FOR PUBLIC INSPECTION UNDER IOWA CODE § 22.11 ___________________________VS. ____________________________________File \ No,._______________ Claimant Employer PROOF OF SERVICE On the _______day of_________________, ______, I mailed a copy of the fo\ regoing original notice and petition by certified mail, return receipt requested, to the employer's \ last known address which is ________________________________________________________________________\ ________________ I CERTIFY under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true and correct. Date__________________________ Signature _______________________________\ _____________________________________ ANSWER (Employer/Insurance Carrier must answer on this form) 1. Employer/Insurance Carrier admit all allegations of the petition except those contained in paragraphs 1. (Enter numbers)_________________________________________which are expressly denied. 2. Employer/Insurance Carrier consent to pay the requested rehabilitation benefit. 3. Evidentiary hearing under Iowa Code section 17A.12 is waived. On behalf of the employer and insurance carrier and based upon my own knowledge of the circumstances, I certify under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding answer is true and correct. Date:_________________________________________ _____ Employer ___________________________________________________ ________________________________________________ Signature of Person Answering Street ______________________________________________________ Name ___________________________________________ City _____________________________State ______Zip _____________ Title ____________________________________________ Phone (Include Area Code) _____________________________________ (If Represented by Attorney) Insurer: _____________________________________________________ Attorney _________________________________________ Street_______________________________________________________ Street ___________________________________________ City_____________________________State_______Zip______________ City ____________State__________Zip________________ Phone (include Area Code)______________________________________ Phone (Include Area Code)__________________________ ORDER (Completed by the deputy workers' compensation commissioner) … The allegations of the petition are found to be true. … The application is granted. Employer/Insurance Carrier shall pay claimant the requested vocational rehabilitation benefit … of $20.00/$100.00 per week for _________ weeks commencing when the training commences. … The application is denied. … Reason:_________________________________________________________________\ ____________________________ … The application will be scheduled for an evidentiary hearing. You will be mailed notice of the time and location of the hearin g. Signed and filed this___________________________________day___________________________________, _________________ Deputy Workers' Compensation Commissioner _________________________________________________________________\ ___ Copies To: Attorney(s) at Law or Pro Se_____________________________ Attorney(s) at Law or Pro Se______________________ INSTRUCTIONS - BOTH PARTIES MUST USE THIS FORM To Claimant: 1. Have your Vocational Rehabilitation Counselor complete the first part of this form. 2. You must attach to this form a copy of the physician's report which shows that the injury caused permanent disability wh ich prevents you from returning to gainful employment and the claimant’s confidentia l information sheet. 3. Deliver a copy of this form with the front page comp leted and the physician’s report to the employer by certified mail, return receipt requested or by personal service as in civil actions (rule 876 IAC 4.7) and mail a copy to the employer’s attorney of record for this file if known (rule 876 IAC 4.13). 4. Complete the proof of service por tion of the original of this form and deliver this entire form with the physician's report to the Division of Workers' Compensation at 1000 East Grand Avenue, Des Moines, Iowa 50319-0209. 5. If you desire an evidentiary hearing, delete paragraph "4" of the petition and in its place enter "I request a hearing.” Rule 876 IAC 4.4. 6. The benefit is $20.00 per week, $100 for injuri es after September 6, 2004, not to exceed 26 weeks. To Employer/Insurance Carrier: 1. Enter the number of each paragraph of the petition which is denied in the space provided in paragraph "1" of the answer. 2. If you do not consent to the requested rehabilitation benefit, delete paragraph "2" of the answer. 3. If you desire an evidentiary hearing, delete paragraph "3" of the answer and in its place enter "I request a hearing. “ Rule 876 IAC 4.4. 4. Serve a copy of your answer to the claimant or claimant's attorney pursuant to rule 876 IAC 4.13. 5. Type or print the name and title of the person answering below the signature. 14-0009 (11-06)