Form 14-0083 - Request For Copies Of Workers' Compensation Files
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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 (12/04)
PLEASE USE THIS FORM TO REQUEST COPIES OF WORKERS' COMPENSATION FILES
____________________________________________________________________________
EMPLOYEE NAME (INCLUDE MIDDLE INITIAL OR NAME)
EMPLOYEE SOCIAL SECURITY NUMBER
BIRTH DATE
_________________________________________________________________________
EMPLOYEE ADDRESS
_______________________________________________________________________________________
EMPLOYER NAME(S)
_______________________________________________________________________________________
EMPLOYER ADDRESS
_______________________________________________________________________________________
DATE(S) OF INJURY/File number(s) if known
_______________________________________________________________________________________
A COPY OF THE FOLLOWING PORTIONS OF THE FILE/RECORD IS REQUESTED:
Entire File with exhibits and transcript
Entire File without exhibits and transcript
Original Notice & Petition
Decisions - file name & no._____________________
First Report
Screen Print
Settlement Documents
Subsequent Reports of Injury
Payments Reported
Other documents, please specify:____________________________________________________
_______________________________________________________________________________
Delivery Method:
Mail (A stamped, self-addressed envelope is required.)
Pick up
Fax - (_______) _________________________
Call for pick up (
)- ________________________________________
In addition to the above requested injury date, search*:
approximately 5 years**,
10 to 15 years**
*
Pursuant to Iowa Administrative Code 876-9.3(7), an hourly search and supervisory fee will be charged
for services based on a $24.00 per hour fee based on 15-minute increments. Minimum search fee $6.00.
Limit charge to $__________________
**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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Parent category: Legal