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Form 14-0037 - Application And Consent Order For Payment Of Benefits - Iowa Workers' Compensation Commissioner

BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER

______________________________________________________________________________

File No. ______________________________

____________________________

Claimant,

Date of Injury: _________________________

Address:_________________________:

Soc. Sec. No.: _________________________

____________________________

Employer,

APPLICATION AND CONSENT

Address: ________________________ :

ORDER FOR PAYMENT OF

____________________________

BENEFITS UNDER IOWA CODE

Insurance Carrier.

SECTION 85.21

Address: _______________________

______________________________________________________________________________

APPLICATION

The employer or insurance carrier below named, without admitting liability, hereby applies

for and consents to an order of the Iowa Workers’ Compensation Commissioner under section

85.21, requiring the payment of weekly benefits and authorized section 85.27 benefits under

chapters 85, 85A, or 85B. Payment of these benefits shall be subject to termination under the

provisions of Iowa Code section 86.13. The other parties to the liability dispute are:

______________________________________________________________________________

Dated this _____ day of ____________________________, _____________.

________________________________

EMPLOYER/INSURANCE CARRIER

BY:

____________________________

(

:)_____________________________

Type or Print name

ORDER

IT IS ORDERED pursuant to Iowa Code section 85.21 that the above insurance carrier or

employer pay benefits as consented above. The issuance of this order does not constitute a

determination of liability.

The consenting insurance carrier or employer may petition, cross-petition, or intervene in

proceedings before this agency as provided in section 85.21, to seek determination of liability and

reimbursement from another carrier or employer for benefits paid pursuant to this order. A copy of

this order shall be attached to the petition if reimbursement is sought. A first report of injury and

subsequent reports of injury shall be filed to report payments paid pursuant to this order.

Signed and filed this ______ day of _________________________, _____________.

14-0037

DEPUTY WORKERS’ COMPENSATION COMMISSIONER

9/02

Form 14-0037 - Application And Consent Order For Payment Of Benefits - Iowa Workers' Compensation Commissioner

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