COPY/INFORMATION REQUEST 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: Contested case pleadings, motions, settlement applications and the resulting decisions, ruling, or orders are public records. First reports of injury, subsequent reports of injury and other information that is filed as a result of an employee's injury or death and that allows identification of the employee or the employee's dependents is confidential information that may not be disclosed without a waiver by the employee except under limited circumstances. Iowa Code section 86.45 I request only public records A waiver signed by each person whose records are sought is provided. I am entitled to the confidential information under section 86.45(2)(_______). Screen prints are acceptable. Delivery Method: Mail (A stamped, self-addressed envelope is required.) Pick up Email ________________________________ Fax - (____)-_________________________ Call for pick up (____)-________________________________________ In addition to the above requested injury date, search: Approximately the past 5 years**, 10 to 15 years** I agree to pay the search fee of $35 per hour, with a minimum fee of $35 and a copy fee of $.15 per page. Contact me before proceeding further if the search fee reaches $___________ or if the copy fee will exceed $_________________ **These files are ordered from state records center and may take 3 to 4 weeks to retrieve. Send by mail 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.) 14-0083 (03/10) American LegalNet, Inc. www.FormsWorkFlow.com