BEFORE THE IOWA WORKERS' COMPENSATION COMMISSIONER ______________________________________________________________________________ : _____________________________ : Claimant : File No.: ________________________ _____________________________ : Address : Injury Date: ______________________ : ____________________________ : Employer : : APPLICATION AND CONSENT _____________________________ : ORDER FOR PAYMENT Address : BENEFITS UNDER IOWA CODE : SECTION 85.21 ____________________________ : Insurance Carrier : ____________________________ : Address : ______________________________________________________________________________ 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 section 85.21, requiring the payment of weekly benefits and authorized section 85.27 benefits under chapters 85, 85A, or 85B. Payment of these benefits shall be subject to termination under the provisions of Iowa Code section 86.13. The other parties to the liability dispute are: ______________________________________________________________________________ ______________________________________________________________________________ Dated this _____ day of ____________________________, _____________. ________________________________ EMPLOYER/INSURANCE CARRIER BY: ____________________________ (Type or Print name:)_____________________________ 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. The consenting insurance carrier or employer may petition, cross-petition, or intervene in proceedings before this agency as provided in section 85.21, to seek determination of liability and reimbursement from another carrier or employer for benefits paid pursuant to this order. A copy of this order shall be attached to the petition if reimbursement is sought. A first report of injury and subsequent reports of injury shall be filed to report payments paid pursuant to this order. Signed and filed this ______ day of _________________________, _____________. 14-0037 (8-09) DEPUTY WORKERS' COMPENSATION COMMISSIONER American LegalNet, Inc. www.FormsWorkFlow.com