Terry E. Branstad, Governor Kim Reynolds, Lt. Governor Beth Townsend, Director Division of Workers' Compensation Joseph S. Cortese II Workers' Compensation Commissioner DIVISION OF WORKERS' COMPENSATION CHARGE ACCOUNT APPLICATION If you wish to be billed monthly for charges incurred with the Division of Workers' Compensation, please complete the bottom section of this letter and return a copy of the letter completed to us. An invoice will be issued following the end of each month including the name (when available) of the person ordering the material, information identifying the material sent, and any amounts incurred. We request that all invoices be paid promptly to avoid the necessity of discontinuing this service. Should your account not be paid within 30 days, your account will be closed to further charging until the past due amount is paid in full. The charge account system may not be used for charging filing fees on workers' compensation cases. See 876--Chapter 4, Iowa Administrative Code for filing fee procedures. Thank you. --------------------------------------------------------------------------------------------------------------------The undersigned desires to be billed on a monthly basis for charges incurred with the Division of Workers' Compensation for copies and searches. The undersigned agrees to pay all costs within thirty (30) days of the receipt of the invoice for same. ______________________________________________________________________ Company Name Address City/State Zip Code (Please Print) ______________________________________________________________________ Name (Please Print) Title Phone Number ______________________________________________________________________ Signature 14-0093 02/15 1000 East Grand Avenue · Des Moines, Iowa 50319-0209 · Phone 515-281-5387 · 800-562-4692 · Fax 515-281-6501 www.iowaworkforce.org/wc Equal Opportunity Employer/Program Auxiliary aids and services are available upon request to individuals with disabilities. For deaf and hard of hearing, use Relay 711. American LegalNet, Inc. www.FormsWorkFlow.com