14-0009 (2/04) (TYPE OR PRINT) FORM 100B BEFORE THE IOWA WORKERS COMPENSATION COMMISSIONER Claimant_________________________________________ File Number_____________________________________ Street____________________________________________ ORIGINAL NOTICE, PETITION, ANSWER AND ORDER City_________________State______Zip________________ CONCERNING VS. Employer_________________________________________ VOCATIONAL REHABILITATION PROGRAM BENEFIT Street____________________________________________ (Iowa Code Section 85.70) City_________________State______Zip_______________ Claimants Soc. Sec. No,____________________________________ Insurance Carrier__________________________________ Injury Date_______________________________________ Street____________________________________________ City_________________State______Zip________________ Body Part(s) Injured________________________________ ORIGINAL NOTICE To the Above-Named Employer: You are notified that an action has been commenced before the Iowa Workers Compensation Commissioner seeking relief as set forth in the petition below. You are required to file and serve an answer to the petition (SEE REVERSE SIDE OF FORM) within 20 days following your receipt of this document or to otherwise move or respond as provided by Division of Workers Compensation rules. Failure to comply may result in the imposition of sanctions under rule 876 IAC 4.36 and/or entry of a default and an award for the relief requested. NOTE: You should promptly advise your workers compensation insurance carrier and attorney that you have received this notice. PETITION (To Be Completed By Claimant and Vocational Rehabilitation Counselor) Claimant requests a vocational rehabilitation program benefit in accordance with Iowa Code section 85.70, as follows: Training Facility________________________________________________________________________ ___________________________________________ NAME CITY STATE Type of Training________________________________________________________________ __________________________________________________ Training will be for ____________weeks, commencing________________________________, ________. This training is part of a vocational rehabilitation program rec ognized by the State Board for Vocational Education. Completion of the program will likely accomplish rehabilitation. Signature of Rehabilitation Counselor_________________________________________Date Si gned_______________________Phone ( ) ________________ IN SUPPORT of this request claimant states: 1. Claimant sustained injury arising out of and in the course of employment with the employer on (Date)___________________________________ 2. The injury occurred at (City) ______________________________________ (County) __________________ (State)____________________ __ 3. Claimant has not returned to gainful employment and cannot do so because of permanent disability resulting from the injury as shown by the attached medical report. 4. Evidentiary hearing under Iowa Code section 17A.12 is waived. I, (Claimants Signature) __________________________________________, Date Signe d____________________________________ certify, under penalty of perjury and pursuant to the laws of the Claimants Phone No. State of Iowa, that the preceding petition is true and correct. (Include Area Code)_________________________________________ (If Represented by Attorney) Attorney__________________________________________________ Street____________________________________________________ City__________________________State___________Zip__________ ________________________________________ Phone (Include Area Code)___________________________________ Signature of Attorney THE INFORMATION PROVIDED WILL BE OPEN FOR PUBLIC INSPECTION UNDER IOWA CODE 22.11 >>>> 2___________________________VS. ____________________________________File No,._______________ Claimant Employer PROOF OF SERVICE On the _______day of_________________, ______, I mailed a copy of the fo regoing original notice and petition by certified mail, return receipt requested, to the employers last known address which is ________________________________________________________________________ ________________ I CERTIFY under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true and correct. Date__________________________ Signature _______________________________ _____________________________________ ANSWER (Employ er/Insurance Carrier must answ er on this form) 1. Employer/Insurance Carrier admit all allegations of the petition except those contained in paragraphs 1. (Enter numbers)_________________________________________which are expressly denied. 2. Employer/Insurance Carrier consent to pay the requested rehabilitation benefit. 3. Evidentiary hearing under Iowa Code section 17A.12 is waived. On behalf of the employer and insurance carrier and based upon my own knowledge of the circumstances, I certify under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding answer is true and correct. Date:______________________________________________ Employer ___________________________________________________ ________________________________________________ Signature of Person Answering Street ______________________________________________________ Name ___________________________________________ City _____________________________State ______Zip _____________ Title ____________________________________________ Phone (Include Area Code) _____________________________________ (If Represented by Attorney) Insurer: _____________________________________________________ Attorney _________________________________________ Street_______________________________________________________ Street ___________________________________________ City_____________________________State_______Zip______________ City ____________State__________Zip________________ Phone (include Area Code)______________________________________ Phone (Include Area Code)__________________________ ORDER (Completed by the deputy workers compensatio n commissio ner) The allegations of the petition are found to be true. The application is granted. Employer/Insurance Carrier shall immediately pay claimant the requested vocational rehabilitation benefit of $20.00 per week for _________ weeks. The application is denied. Reason:_________________________________________________________________ ____________________________ The app