Form 100a 14-0007 - Original Notice And Petition, Answer And Order Concerning Independent Medical Examination 2014 Page 2
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1
2VS.
File No.
___________________________________
_______________________________
_________________
Claimant
Employer
PROOF OF SERVICE
On the _________ day of ________________________, _________, I mailed a copy of the foregoing original notice and petition by
certified mail, return receipt requested, to the employer’s last known address which is: _________________________
___________________________________________________________________________________________________________
I CERTIFY under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true and correct.
Date ____________________________
Signature ___________________________________________________________
ANSWER (Employer/Insurance Carrier must answer on this form)
1. Employer/Insurance Carrier admit all allegations of the petition except those contained in paragraphs
(Enter numbers) ______________________________________________ which are expressly denied.
2. Employer/Insurance Carrier consent to pay the reasonable expenses of the requested examination.
3. Evidentiary hearing under Iowa Code section 17A.12 is waived.
On behalf of the employer and insurance carrier and based upon my own knowledge of the circumstances, I certify under penalty of perjury and pursuant
to the laws of the State of Iowa that the preceding answer is true and correct.
Date: ____________________________________
Employer
________________________________________________________
Signature of Person Answering
____________________________________________________
Street
Name: _________________________________________________
______________________________________________________
Title: ___________________________________________________
City _______________________ State __________ Zip ________
Phone (Include Area Code) ________________________________
(If Represented by Attorney)
Attorney _________________________________________________
Street __________________________________________________
Insurer __________________________________________________
City ___________________________ State __________ Zip _____
Street ______________________________________________
Phone (Include Area Code) _________________________________
City ____________________________ State __________ Zip ____
Phone (Include Area Code) _________________________________
ORDER (Completed by the deputy workers' compensation commissioner)
The allegations of the petition are found to be true.
The application is granted. Employer/Insurance Carrier shall immediately reimburse claimant the reasonable expenses of the requested
examination, including travel expenses.
The application is denied. Reason: ___________________________________________________________________________________
The application will be scheduled for an evidentiary hearing. You will be mailed notice of the time and location of the hearing.
Signed and filed this ________________ day of ______________________________________________________________, __________________
Deputy Workers' Compensation Commissioner ___________________________________________________________________________________
Copies To: Attorney(s) at Law or Pro Se ________________________________ Attorney(s) at Law or Pro Se _______________________________
INSTRUCTIONS - BOTH PARTIES MUST USE THIS FORM
To Claimant:
1.
You must attach to this form a copy of the physician’s report which evaluates your permanent disability to support paragraph “3” of the petition.
2.
Deliver a copy of this form with the front page completed and the physician’s report to the employer by certified mail, return receipt
requested
or by personal services as in civil actions (rule 876 IAC 4.7) and mail a copy to the employer’s attorney of record for this file if known (rule 876
IAC 4.13).
3.
Complete the proof of service portion on the original of this form and deliver this entire form with the physician’s report to the Division of
Workers' Compensation at 1000 East Grand Avenue, Des Moines, Iowa 50319-0209.
4.
If you desire an evidentiary hearing, delete paragraph “6” of the petition and in its place enter “I request a hearing.” Rule 876 IAC 4.4.
To Employer/Insurance Carrier:
1
Enter the number of each paragraph of the petition which is denied in the space provided in paragraph “1” of the answer.
2
If you do not consent to the requested examination, delete paragraph “2” of the answer.
3.
If you desire an evidentiary hearing, delete paragraph “3” of the answer and in its place enter “I request a hearing.” Rule 876 IAC 4.4.
4.
Serve a copy of your answer to the claimant or claimant’s attorney pursuant to rule 876 IAC 4.13.
5
Type or print the name and title of the person answering below the signature line.
14-0007 (Back) (5/04)
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