Form 100a 14-0007 - Original Notice And Petition, Answer And Order Concerning Independent Medical Examination 2014
ADVERTISEMENT
1
2(TYPE OR PRINT)
Form 100A
BEFORE THE IOWA WORKERS' COMPENSATION COMMISSIONER
14-0007 (5/04)
Claimant ________________________________
File Number ________________________
Street ___________________________________
ORIGINAL NOTICE, PETITION,
ANSWER AND ORDER
City _______________State ____Zip __________
CONCERNING
VS
Employer ________________________________
INDEPENDENT
Street ___________________________________
MEDICAL EXAMINATION
(Iowa Code Section 85.39)
City _______________State ____Zip __________
Insurance Carrier __________________________
Claimant’s
Street ___________________________________
Soc. Sec.
No.________________________
City _______________State ____Zip __________
Injury Date _________________________
Body Part(s)
Injured___________________
ORIGINAL NOTICE
To the Above-Named Employer:
You are notified that an action has been commenced before the Iowa Workers' Compensation Commissioner seeking relief as set
forth in the petition below. You are required to file and serve an answer to the petition (SEE REVERSE SIDE OF FORM) within 20 days
following your receipt of this document or to otherwise move or respond as provided by Division of Workers' Compensation rules.
Failure to comply may result in the imposition of sanctions under rule 876 IAC 4.36 and/or entry of a default and an award for the relief
requested. NOTE: You should promptly advise your workers’ compensation insurance carrier and attorney that you have received this
notice.
PETITION (To Be Completed By Claimant)
Claimant requests
an independent medical evaluation, at the employer’s expense, in accordance with Iowa Code section 85.39, as follows:
Physician Name ____________________________________________________ Examination Date _______________________
Examination Location (City) _________________________________________ State __________________________________
In support of this request claimant states:
1. Claimant sustained injury arising out of and in the course of employment with the employer on (Date) ______________.
2. The injury occurred at (City) ________________________ (County) ____________________ (State) ________________.
3. An evaluation of permanent disability has been made by (Physician Name) _______________________________________.
as shown on the attached written report, and claimant believes the evaluation is too low.
4. The physician named in paragraph 3 above was retained or paid by the employer and/or insurance carrier.
5. The injury referred to in paragraph 1 was a factor in producing the condition for which the evaluation was made.
6. Evidentiary hearing under Iowa Code section 17A.12 is waived.
I, (Claimant’s Signature) ___________________________________________, Date Signed
____________________
certify, under penalty of perjury and pursuant to the laws of
Claimant’s Phone (Include Area Code)
the State of Iowa, that the preceding petition is true and
_____________________________________
correct.
(If Represented by Attorney)
______________________________________
Attorney ______________________________________________________
Signature of Attorney
Street _______________________________________________________
City ________________________________ State __________ Zip _______
Phone No ____________________________________
THE INFORMATION PROVIDED WILL BE OPEN FOR PUBLIC INSPECTION UNDER IOWA CODE §22.11
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 8843 - Statement For Exempt Individuals And Individuals With A Medical Condition - 2014
Financial
Form 100b - Original Notice, Petition, Answer And Order Concerning Vocational Rehabilitation Program Benefit - 2004
Legal
Related Categories
Parent category: Legal