Looking for a Iowa Workers Compensation Forms And Templates? Download it for free!

Form 14-0037 - Application And Consent Order For Payment Of Benefits Under Iowa Code Section 85.21 - 1999

BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER

File No. __________________

_____________________________________________________________________________

___________________________

Claimant,

____________________________

APPLICATION AND CONSENT

Employer,

ORDER FOR PAYMENT OF

BENEFITS UNDER IOWA CODE

____________________________

SECTION 85.21

Insurance Carrier.

______________________________________________________________________________

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 Iowa Code

section 85.21, requiring the payment of weekly benefits under chapters 85, 85A, or 85B of the

Code of Iowa to the claimant at the rate of $___________________ per week commencing

_________________________, ______, as a result of an alleged injury or disease occurring on or

about __________________, _____, and, also, all authorized and causally related medical

expenses under Iowa Code section 85.27. Payment of these benefits shall be subject to

termination under the provisions of Iowa Code section 86.13. The reason for this application is

_____________________________________________________________________________

Dated this _____ day of ______________, _____.

________________________________

EMPLOYER/INSURANCE CARRIER

BY: _________________________

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.

By virtue of this order and only for purposes expressed in Iowa Code section 85.21, the

above named insurance carrier or employer may commence a contested case proceeding, cross-

petition or intervene in proceedings before this agency as allowed under the rules of the Iowa

Workers’ Compensation Commissioner and the Iowa Rules of Civil Procedure to seek a

determination of liability, reimbursement for benefits paid and recovery of interest as provided in

Iowa Code section 85.30 from another carrier or employer due to payments made in accordance

with this order.

Signed and filed this ______ day of _______________, ____.

____________________________________________

14-0037

DEPUTY WORKERS’ COMPENSATION COMMISSIONER

7/99

Form 14-0037 - Application And Consent Order For Payment Of Benefits Under Iowa Code Section 85.21 - 1999

Related Articles

Related forms

Related Categories