Form 14-0083 - Copy/information Request - Iowa printable pdf download

COPY/INFORMATION REQUEST

PLEASE USE THIS FORM TO REQUEST COPIES OF WORKERS' COMPENSATION FILES

____________________________________________________________________________

EMPLOYEE NAME (INCLUDE MIDDLE INITIAL OR NAME)

EMPLOYEE SOCIAL SECURITY NUMBER

BIRTH DATE

____________________________________________________________________________

EMPLOYEE ADDRESS

_______________________________________________________________________________________

EMPLOYER NAME(S)

_______________________________________________________________________________________

EMPLOYER ADDRESS

_______________________________________________________________________________________

DATE(S) OF INJURY/File number(s) if known

_______________________________________________________________________________________

A COPY OF THE FOLLOWING PORTIONS OF THE FILE/RECORD IS REQUESTED:

Contested case pleadings, motions, settlement applications and the resulting decisions, ruling, or orders are public

records. First reports of injury, subsequent reports of injury and other information that is filed as a result of an

employee’s injury or death and that allows identification of the employee or the employee’s dependents is

confidential information that may not be disclosed without a waiver by the employee except under limited

circumstances. Iowa Code section 86.45

I request only public records

A waiver signed by each person whose records are sought is provided.

I am entitled to the confidential information under section 86.45(2)(_______).

Delivery Method:

Mail (A stamped, self-addressed envelope is required.)

Pick up

Fax - (_______) _________________________

Call for pick up (

)- ________________________________________

In addition to the above requested injury date, search:

Approximately the past 5 years**,

10 to 15 years**

I agree to pay the search fee of $24 per hour, with a minimum fee of $6 and a copy fee of $.10 per page over

the first 10 pages.

Contact me before proceeding further if the search fee reaches $___________ or if the copy fee will exceed

$_________________

**These files are ordered from state records center and may take 3 to 4 weeks to retrieve.

Send to: _________________________________________________________________

Firm or Company:__________________________________________________________

Mailing Address:___________________________________________________________

Telephone Number: (

)____________________________________________________

Charge to Account Number: _______________________________________________

Bill my firm (an advance deposit for the full amount is requested before copies are released.)

14-0083 (07/05)

Form 14-0083 - Copy/information Request - Iowa

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