(TYPE OR PRINT) BEFORE THE IOWA WORKERS' COMPENSATION COMMISSIONER Claimant ________________________________ Form 100A 14-0007 (01/09) File Number ________________________ VS Employer ________________________________ Street ___________________________________ City _______________State ____Zip __________ Insurance Carrier __________________________ Street ___________________________________ City _______________State ____Zip __________ ORIGINAL NOTICE, PETITION, ANSWER AND ORDER CONCERNING INDEPENDENT MEDICAL EXAMINATION (Iowa Code Section 85.39) Injury Date _________________________ 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) Claimant requests an independent medical evaluation, at the employer's expense, in accordance with Iowa Code section 85.39, as follows: Physician Name ____________________________________________________ Examination Date _______________________ Examination Location (City) _________________________________________ State __________________________________ 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. An evaluation of permanent disability has been made by (Physician Name) _______________________________________. as shown on the attached written report, and claimant believes the evaluation is too low. 4. The physician named in paragraph 3 above was retained or paid by the employer and/or insurance carrier. 5. The injury referred to in paragraph 1 was a factor in producing the condition for which the evaluation was made. 6. Evidentiary hearing under Iowa Code section 17A.12 is waived. I, (Claimant's Signature) __________________________________________, Date Signed ____________________ certify, under penalty of perjury and pursuant to the laws of the State of Iowa, that the preceding petition is true and correct. (If Represented by Attorney) Attorney ______________________________________________________ Street _______________________________________________________ City ________________________________ State __________ Zip _______ ______________________________________ Claimant's Phone (Include Area Code) _____________________________________ Signature of Attorney ______________________________________ Phone No ____________________________________ Fax No. _____________________________________ Email Address of Attorney THE INFORMATION PROVIDED WILL BE OPEN FOR PUBLIC INSPECTION UNDER IOWA CODE §22.11 American LegalNet, Inc. www.FormsWorkFlow.com ___________________________________ VS. _______________________________ File No. _________________ Claimant Employer PROOF OF SERVICE On the _________ day of ________________________, _________, I mailed a copy of the foregoing original notice and petition by certified mail, return receipt requested, to the employer's 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 (Employer/Insurance Carrier must answer on this form) 1. Employer/Insurance Carrier admit all allegations of the petition except those contained in paragraphs (Enter numbers) ______________________________________________ which are expressly denied. 2. Employer/Insurance Carrier consent to pay the reasonable expenses of the requested examination. 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 ____________________________________________________ Street ______________________________________________________ City _______________________ State __________ Zip ________ Phone (Include Area Code) ________________________________ (If Represented by Attorney) Attorney _________________________________________________ Street __________________________________________________ City ___________________________ State __________ Zip _____ Phone (Include Area Code) _______________________________ Fax Number (include Area Code) ____________________________ Email Address: ___________________________________________ ________________________________________________________ Signature of Person Answering Name: _________________________________________________ Title: ___________________________________________________ Insurer __________________________________________________ Street ______________________________________________ City ____________________________ State __________ Zip ____ Phone (Include Area Code) _________________________________ ORDER (Completed by the deputy workers' compensation commissioner) Allegations 3 and 4 of the petition are found to be true. The application is granted. Employer/Insurance Carrier shall immediately reimburse claimant the reasonable expenses of the requested examination, including travel expenses. The application is denied. Reason: ___________________________________________________________________________________ The application will be scheduled for an evidentiary hearing. You will be mailed notice of the time and location of the hearing. Signed and filed this ________________ day of ______________________________________________________________, __