Form 9-14-0013 - Original Notice And Petition And Order For Commutation
ADVERTISEMENT
1
2BEFORE THE IOWA WORKERS' COMPENSATION COMMISSIONER
FORM 9 - 14-0013 (7/05)
File No._____________
front
SS# ___________________
______________________________________________
________________________
Claimant
VS.
(Injury Date)
ORIGINAL NOTICE AND PETITION
______________________________________________
AND ORDER
Employer
FOR COMMUTATION OF
ALL REMAINING BENEFITS
______________________________________________
OF 10 WEEKS OR MORE 876 IAC 6.2(6)
Insurance Carrier
To Employer and Insurance carrier: You are notified that an action for commutation of all remaining benefits 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 Full Commutation of all 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.
Commuted Value ....................................
_____________________ X ____________________________ = $ ____________________
Factor
Weekly Rate
Commuted Value
7.
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
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 100a 14-0007 - Original Notice And Petition, Answer And Order Concerning Independent Medical Examination 2014
Legal
Form Cv-449 - Notice And Order For Injunction Hearing When Temporary Restraining Order Is Not Issued
Legal
Form Dr-16r Draft - Renewal Notice And Application For Sales And Use Tax Direct Pay Permit
Financial
Form Dr-700032 Draft - Renewal Notice And Application For Self-accrual Authority/ Direct Pay Permit - Communications Services Tax
Financial
Related Categories
Parent category: Legal