Fill and Sign the Vs Employer Form

Claimant ________________________________ Employer ________________________________ Street ___________________________________ City _______________State ____Zip __________ Insurance Carrier __________________________ Street ___________________________________ City _______________State ____Zip __________ File Number ________________________ ORIGINAL NOTICE, PETITION, ANSWER AND ORDER CONCERNING INDEPENDENT MEDICAL EXAMINATION (Iowa Code Section 85.39) Injury Date _________________________ Body Part(s) Injured___________________ ORIG INAL NOTICE To the Above -Named Employer: You are notified that an action has been commenced before the Iowa Workers' Compensation 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) Claimant requests an independent medical evaluation, at the employer’s expense, in accordance with Iowa Code section 85.39, as follows: Physician Name ____________________________________________________ Examination Date _______________________ Examination Location (City) _________________________________________ State __________________________________ In support of this request claimant states: 1. C laimant 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. An evaluation of permanent disability has been made by (Physician Name) _______________________________________. as shown on the attached written report, and claimant believes the evaluation is too low. 4. The physician named in paragraph 3 above was retained or paid by the employer and/or insurance carrier. 5. The injury referred to in paragraph 1 was a factor in producing the condition for which the evaluation was made. 6. Evidentiary hearing under Iowa Code section 17A.12 is waived. I, (Claimant’s Signature) __________________________________________, Date Signed ____________________ certify, under penalty of perjury and pursuant to the laws of the State of Iowa, that the preceding petition is true and correct. (If Represented by Attorney ) Attorney ______________________________________________________ Street _______________________________________________________ City ________________________________ State __________ Zip _______ Claimant’s Phone (Include Area Code) _____________________________________ ______________________________________ Signature of Attorney ______________________________________ Phone No ____________________________________ Email Address of Attorney Fax No. _____________________________________ THE INFORMATION PROVIDED WILL BE OPEN FOR PUBLIC INSPECTION UNDER IOWA CODE §22.11 (TYPE OR PRINT) BEFORE THE IOWA WORKERS' COMPENSA TION COMMISSIONER Form 100A 14-0007 (01/09) VS ___________________________________ VS. _______________________________ File No. _________________ Claimant Employer PROOF OF SERVICE On the _________ day of ________________________, _________, I mailed a copy of the foregoing 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 ____________________________ S ignature ___________________________________________________________ ANSWER (Employer/Insurance Carrier must answer on this form) 1. Employer/Insurance Carrier admit all allegations of the petition except those contained in paragraphs (Enter numbers) ______________________________________________ which are expressly denied. 2. Employer/Insurance Carrier consent to pay the reasonable expenses of the requested examination. 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 ____________________________________________________ Street ______________________________________________________ City _______________________ State __________ Zip ________ Phone (Include Area Code) ________________________________ Insurer __________________________________________________ Street ______________________________________________ City ____________________________ State __________ Zip ____ Phone (Include Area Code) _________________________________ ________________________________________________________ Signature of Person Answering Name: _________________________________________________ Title: ___________________________________________________ (If Represented by Attorney) Attorney _________________________________________________ Street __________________________________________________ City ___________________________ State __________ Zip _____ Phone (Include Area Code) _______________________________ Fax Number (include Area Code) ____________________________ Email Address: ___________________________________________ ORDER (Completed by the deputy workers' compensation commissioner)  Allegations 3 and 4 of the petition are found to be true.  The application is granted. Employer/Insurance Carrier shall immediately reimburse claimant the reasonable expenses of the requested examination, including travel expenses.  The application is denied. Reason: ___________________________________________________________________________________  The application will be heard as an issue in an arbitration decision and should be identified as an issue in the hearing report. Signed and filed this ________________ day of ______________________________________________________________, __________________ 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. You must attach to this form a copy of the physician’s report which evaluates your permanent disability to support paragraph “3” of the petition. You must also attach the claimant’s confidential information sheet. 2. Deliver a copy of this form with the front page completed and the physician’s report to the employer by certified mail, return receipt requested or by personal services 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). 3. Complete the proof of service portion on 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. 4. If you desire an evidentiary hearing, delete paragraph “6” of the petition and in its place enter “I request a hearing.” Rule 876 IAC 4.4. 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 examination, 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 line. 14-0007 (Back) (01/09)