Form 9a-14-0017 - Original Notice And Petition And Order For Partial Commutation Page 2
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1
2D.
I am the person entitled to workers' compensation benefits on account of the indicated injury or death. I have read the foregoing and all attachments.
I consent to the degree of disability and the granting of the commutation. In the event the employer consents to the commutation, I waive any provision
concerning contested cases as provided in Chapter 17A or otherwise.
If I am not represented, I waive my right to an attorney
____________________________________________________________
____________________________________________________________
Claimant’s Attorney
Date
Claimant
Date
E.
EMPLOYER
1.
The employer/insurance carrier consents to the degree of disability and the granting of the commutation and waives any
provision concerning contested cases as provided in Chapter 17A or otherwise.
______________________________________________________________
Employer/Insurance Carrier
Date
2.
The employer/insurance carrier resists the relief sought in the petition for commutation but acknowledges delivery of a
copy of the original notice and petition.
(Check one)
A hearing is waived
A hearing is requested
______________________________________________________________
Employer/Insurance Carrier
Date
The foregoing Application for Commutation is approved and the relief sought is granted ________________________ , _______ .
___________________________________________________
Iowa Workers’ Compensation Commissioner
NOTICE TO APPLICANT
DELIVERY OF FORM
1. Delivery of this form is to be by personal service as in civil actions or by certified mail, return receipt requested. Rule 876
IAC 4.7.
2. A copy of this form with proof of delivery must be filed with the Division of Workers’ Compensation no later than 10 days
after delivery upon the respondent. Rule 876 IAC 4.8.
3. The Commissioner will not deliver this form to the respondent for a petitioner.
DIVISION OF WORKERS’ COMPENSATION, 1000 EAST GRAND AVENUE, DES MOINES, IOWA 50319-0209 (515) 281-5387
The information provided will be open for public inspection under Iowa Code §§ 22.11 and 86.45(1)
14-0017 BACK (07/05)
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