Copy/information Request - Iowa Division Of Workers' Compensation
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1DIVISION OF WORKERS’ COMPENSATION
1000 East Grand Avenue
Des Moines, Iowa 50319
TELEPHONE - (515) 281-5387
COPY/INFORMATION REQUEST
14-0083 (8-98)
PLEASE USE THIS FORM TO REQUEST COPIES OF WORKERS' COMPENSATION FILES
___________________________________________________________________________
EMPLOYEE NAME (INCLUDE MIDDLE INITIAL OR NAME) EMPLOYEE SOCIAL SECURITY NUMBER
BIRTHDATE
___________________________________________________________________________
EMPLOYEE ADDRESS
___________________________________________________________________________________________
EMPLOYER NAME(S)
____________________________________________________________________________________________
EMPLOYER ADDRESS
___________________________________________________________________________________________
DATE(S) OF INJURY
___________________________________________________________________________________________
A COPY OF THE FOLLOWING PORTIONS OF THE FILE IS REQUESTED
Entire File
Original Notice & Petition
First Report
Settlement Documents
2, 2A & 2B
Other documents, please specify:_____________________________________________________________
Delivery Method:
Mail (A stamped, self-addressed envelope is required.)
Pick up
Call for pick up (
)-_______________________
In addition to the above requested injury date, search*:
apporximately 5 years,
10 to 15 years**
*
Pursuant to Iowa Administrative Code 876-9.3(7), an hourly search and supervisory fees will be charged
for services requiring more than 15 minutes of staff time.
**These files are ordered from state records center and may take 3 to 4 weeks to retrieve.
Send to: _________________________________________________________________
Firm or Company:_________________________________________________________
Mailing Address___________________________________________________________
Telephone Number: (
)__________________________________________________
Charge to Account Number: ____________________________________________
Bill my firm (an advance deposit for the full amount is requested before copies are released.)
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