FORM 9A - 14-0017 (11/06) BEFORE THE IOWA WORKERS' COMPENSATION COMMISSIONER File No. ___________ ______________________________________________ Claimant VS. __________________ (Injury Date) Compliance File No. ____________ (REQUIRED) ______________________________________________ Employer ______________________________________________ Insurance Carrier ORIGINAL NOTICE AND PETITION AND ORDER FOR PARTIAL COMMUTATION To Employer and Insurance carrier: You are notified that an action for partial commutation has been commenced before the workers' compensation commissioner seeking relief under the chapters of the Iowa Code relating to workers' compensation, occupational disease and occupational hearing loss (Chapter 85, 85A, 85B, 86 and 87). A hearing will be held in the judicial district wherein the injury occurred. When applicable, the parties will be notified by the workers' compensation commissioner of the time and place of the prehearing conference and hearing. You are required to file an answer within 20 days of the receipt of this document or to otherwise move or respond as provided by rule 876 IAC 4.9. Failure to comply may result in the imposition of the sanctions of 876 IAC 4.36. Payment Activity Report (PAR) shall match calculation below. A. The undersigned makes Application for Partial Commutation of remaining benefits in the above entitled case and represents: 1. 2. As a result of the compensable injury or death, claimant has suffered a permanent disability equal to _______ % of the ____________ Total Entitlement ................... Temporary Partial Weeks ________________ Amount Paid ________________ 3. Paid to Date .......................... Temporary Partial Weeks ________________ Amount Paid ________________ Healing Period Weeks _______________ Rate _________________ Healing Period Weeks ________________ $ _____________________ Thru ___________________ Date 4. Accrued-Not Paid ................... Temporary/Partial Weeks ________________ Amount Paid ________________ Date 5. 6. 7. 8 9. Remainder .............................................. Commutation of _________________ Weeks for Commuted Value .................................... Remainder After Commutation (if approved) Other Terms Healing Period Weeks _________________ Permanent/Death Weeks _______________ $ ___________________ Rate ________________ Permanent/Death Weeks ______________ $ ___________________ Thru _________________ Date Permanent/Death Weeks _______________ $ ________________ Total Total $ _______________ Pro Rata Last part of remaining period $ _______________ Total $ _______________ Total $ ____________________ $ ______________________ $ ____________________ Thru ____________________ Thru _________________ Date _____________________ Weeks @ $ ___________________ First part of remaining period _____________________ X ____________________________ = $ ____________________ Factor Weekly Rate Commuted Value _____________________ Weeks @ $ __________________ = $ ____________________ Total ________________________________________________________________________________________________________________ B. Attach pertinent, legible medical records not exceeding 20 pages indicating: (1) The degree of disability (2) The condition is not expected to deteriorate (3) The condition is not expected to require future treatment (unless provision has been made for future treatment) C. Statement of Need in dollars and cents. I will use the funds for the following: 1. ___________________________________________________________________________________ 2. ____________________________________________________________________________________ 3. ____________________________________________________________________________________ 4. ____________________________________________________________________________________ Attorney fee disclosure: $______________________________ = _____ % of settlement $ _________________ $ _________________ $ _________________ $ _________________ American LegalNet, Inc. www.FormsWorkFlow.com D. I am the person entitled to workers' compensation benefits on account of the indicated injury or death. I have read the foregoing and all attachments. I consent to the degree of disability and the granting of the commutation. In the event the employer consents to the commutation, I waive any provision concerning contested cases as provided in Chapter 17A or otherwise. If I am not represented, I waive my right to an attorney ____________________________________________________________ Claimant's Attorney Date _____________________________________________________________ Email Address of Attorney ____________________________________________________________ Claimant Date ____________________________________________________________ Fax Number of Attorney E. 1. EMPLOYER The employer/insurance carrier consents to the degree of disability and the granting of the commutation and waives any provision concerning contested cases as provided in Chapter 17A or otherwise. ______________________________________________________________ Employer/Insurance Carrier ___________________________________________________ Email Address of Attorney 2. ______________________________________________________ Fax Number of Attorney The employer/insurance carrier resists the relief sought in the petition for commutation but acknowledges delivery of a copy of the original notice and petition. (Check one) A hearing is waived A hearing is requested ______________________________________________________________ Employer/Insurance Carrier Date _________________________________________________________ Email Address of Attorney __________________________________________________________ Fax Number of Attorney The foregoing Application for Commutation is approved and the relief sought is granted ________________________ , _______ . ___________________________________________________ Iowa Workers' Compensation Commissioner NOTICE TO APPLICANT DELIVERY OF FORM 1. Delivery of this form is to be by personal service as in civil actions or by certified mail, return receipt requested. Rule 876 2. A copy of this form with proof of delivery and claimant's confidential statement must be filed with the Division of Workers' Compensation no later than 10 days after delivery upon the respondent. Rule 876 IAC 4.8. 3. The Commissioner will not deliver this form to the respondent for a petitioner. DIVISION OF WORKERS' COMPENSATION, 1000 EAST GRAND AVENUE, DES