Form 9a-14-0017 - Original Notice And Petition And Order For Partial Commutation
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1
2BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER
FORM 9A - 14-0017 (07/05)
File No. ___________
______________________________________________
________________________ SS# ___________________________
Claimant
VS.
(Injury Date)
ORIGINAL NOTICE AND PETITION
______________________________________________
AND ORDER
Employer
FOR PARTIAL COMMUTATION
______________________________________________
Insurance Carrier
To Employer and Insurance carrier: You are notified that an action for partial commutation has been commenced before the workers’
compensation commissioner seeking relief under the chapters of the Iowa Code relating to workers' compensation, occupational disease and
occupational hearing loss (Chapter 85, 85A, 85B, 86 and 87). A hearing will be held in the judicial district wherein the injury occurred. When
applicable, the parties will be notified by the workers’ compensation commissioner of the time and place of the prehearing conference and
hearing. You are required to file an answer within 20 days of the receipt of this document or to otherwise move or respond as provided by rule
876 IAC 4.9. Failure to comply may result in the imposition of the sanctions of 876 IAC 4.36. Payment Activity Report (PAR) shall match
calculation below.
A. The undersigned makes Application for Partial Commutation of remaining benefits in the above entitled case and represents:
1.
As a result of the compensable injury or death, claimant has suffered a permanent disability equal to _______ % of the ____________
2.
Total Entitlement ................... Temporary Partial
Healing Period
Permanent/Death
Weeks ________________
Weeks _______________
Weeks _______________
$ ____________________
$ ___________________
Amount Paid ________________
Rate _________________
Rate ________________
$ _______________
Total
3.
Paid to Date .......................... Temporary Partial
Healing Period
Permanent/Death
Weeks ________________
Weeks ________________
Weeks ______________
$ _____________________
$ ___________________
Amount Paid ________________
Thru ___________________
Thru _________________
$ _______________
Date
Date
Total
4.
Accrued-Not Paid ................... Temporary/Partial
Healing Period
Permanent/Death
Weeks ________________
Weeks _________________
Weeks _______________
$ ______________________
$ ____________________
Amount Paid ________________
Thru ____________________
Thru _________________
$ ________________
Date
Date
Total
5.
Remainder ..............................................
_____________________ Weeks @ $ ___________________
Total $ _______________
6.
Commutation of _________________ Weeks for
First part of remaining period
Last part of remaining period
Pro Rata
7.
Commuted Value ....................................
_____________________ X ____________________________ = $ ____________________
Factor
Weekly Rate
Commuted Value
8
Remainder After Commutation (if approved)
_____________________ Weeks @ $ __________________ = $ ____________________
Total
9.
Other Terms ________________________________________________________________________________________________________________
B. Attach pertinent, legible medical records not exceeding 20 pages indicating:
(1) The degree of disability
(2) The condition is not expected to deteriorate
(3) The condition is not expected to require future treatment (unless provision has been made for future treatment)
C. Statement of Need in dollars and cents. I will use the funds for the following:
1. ___________________________________________________________________________________ $ _________________
2. ____________________________________________________________________________________ $ _________________
3. ____________________________________________________________________________________ $ _________________
4. ____________________________________________________________________________________ $ _________________
Attorney fee disclosure:
$______________________________ = _____ % of settlement
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