Form 14-0029 - Waiver On Account Of Physical Defect - State Of Iowa

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STATE OF IOWA
WAIVER ON ACCOUNT OF PHYSICAL DEFECT
14-0029 (7-98)
To Be Mailed in Duplicate to
IOWA WORKERS’ COMPENSATION COMMISSIONER
1000 East Grand Avenue
DES MOINES, IOWA 50319
1 ____________________________ ___ _________________________ _____________________________
Employee
Age
Address
Phone
2 ________________________________ _________________________ _____________________________
Employer
Address
Phone
3 _________________________________ __________________________ _____________________________
Examining Physician
Address
Phone
4 Date of employment with the above employer________________________________________________________
PHYSICAL DEFECT:
5.
Description__________________________________________________________________________________________________
Describe fully using functional disability percentages when applicable
______________
6. Origin of Defect: Congenital
Aging or other Natural Process
Disease
Other (except injury)
Explain
__________________________________________________________________________________________________________
Injury
______________________________ Description of Injury _________________________________________________
Approx. Date
Job Related: Yes
No
If yes ____________________________________________________________________________
Name of Employer
___________________________________________________________________
Comments
7 Job activities employee can perform without undue hazard to health or life_______________________________________
8 Necessary restrictions on job activities _________________________________________________________________________
X ______________________________________________
Physician's signature
EMPLOYEE'S STATEMENT:
9 In accordance with the terms and provisions of Iowa Code section 85.55, the undersigned hereby waives compensation for
any and all injuries which may occur directly or indirectly because of the above described physical defect, sustained by
me while in the employ of the above named employer.
X ____________________________________________________
X ____________________________________________
Parent's Signature (If Employee a Minor)
Employee's Signature
EMPLOYER'S STATEMENT:
10 The undersigned employer agrees to this waiver. It is further agreed that the above employee will not be required to perform
work of a more strenuous or hazardous nature than suggested or recommended herein. The undersigned further certifies
the above defect is not a result of an injury which arose out of and in the course of employment with the employer.
X ____________________________________________________
X______________________________________________
Title
Signature
APPROVED:
This waiver of physical defect is approved to the agreements and representations set out herein. Should the employee be required to
perform work of a more strenuous or hazardous nature than suggested or recommended herein, this waiver shall be null and void
during any such period.
_____________________________________________________
X ________________________________________________
Date
Iowa Workers’ Compensation Commissioner
The information provided will be open for public inspection under Iowa Code § 22.11

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