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Form 14-0093 - Charge Account Application - Division Of Workers' Compensation - Iowa

Thomas J. Vilsack, Governor

Sally J. Pederson, Lt. Governor

Richard V. Running, Director

Division of Workers’ Compensation

Michael G. Trier, Workers’ Compensation Commissioner

Putting Iowa

to Work

DIVISION OF WORKERS' COMPENSATION

CHARGE ACCOUNT APPLICATION

You will be billed monthly for charges incurred with the Division of Workers' Compensation, upon

approval of this application. Please return a copy of this letter with the bottom portion filled out as your

application. An invoice will be issued following the end of each month including the name (when available)

of the person ordering the material, information identifying the material sent, and any amounts incurred.

There will also be a copy and postage charge for sending the statement. This charge is based on the current

copy charges and first class postage rates.

All invoices shall be paid promptly to avoid the necessity of discontinuing this service. Should your

account not be paid within 30 days, your account will be closed to further activity until the past due amount is

paid in full.

The charge account system may not be used for charging filing fees on workers’ compensation cases.

See 876--Chapter 4, Iowa Administrative Code for filing fee procedures.

Thank you.

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The undersigned desires to be billed on a monthly basis for charges incurred with the Division of

Workers' Compensation for copies and searches. The undersigned agrees to pay all costs within thirty (30)

days of the receipt of the invoice for same.

______________________________________________________________________________

Company Name

Address

City/State

Zip Code

______________________________________________________________________________

Name (Please Print)

Title

Phone Number

______________________________________________________________________________

Signature

14-0093

6/03

•

1000 East Grand Avenue

Des Moines, Iowa 50319-0209

Phone 515-281-5387

800-562-4692

Fax 515-281-6501

Form 14-0093 - Charge Account Application - Division Of Workers' Compensation - Iowa

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