Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Original Notice Petition Answer And Order Concerning Vocational Rehabilitation Program Benefit Form. This is a Iowa form and can be use in Workers Compensation.
Loading PDF...
Tags: Original Notice Petition Answer And Order Concerning Vocational Rehabilitation Program Benefit, 100B, Iowa Workers Compensation,
(TYPE OR PRINT)
14-0009 (11/06)
FORM 100B
BEFORE THE IOWA WORKERS' COMPENSATION COMMISSIONER
File Number_____________________________________
ORIGINAL NOTICE, PETITION,
ANSWER AND ORDER
CONCERNING
Claimant_________________________________________
VS.
Employer_________________________________________
VOCATIONAL REHABILITATION
Street____________________________________________
PROGRAM BENEFIT
(Iowa Code Section 85.70)
City_________________State______Zip_______________
Insurance Carrier__________________________________
Street____________________________________________
Injury Date_______________________________________
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 recognized by the State Board for Vocational Education. Completion of the
program will likely accomplish rehabilitation.
Signature of
Rehabilitation Counselor_________________________________________Date Signed_______________________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.
3.
The injury occurred at (City) ______________________________________ (County) __________________ (State)______________________
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.
Evidentiary hearing under Iowa Code section 17A.12 is waived.
4.
I, (Claimant's Signature) __________________________________________,
Date Signed____________________________________
certify, under penalty of perjury and pursuant to the laws of the
Claimant's Phone No.
State of Iowa, that the preceding petition is true and correct.
(Include Area Code)_________________________________________
(If Represented by Attorney)
Attorney__________________________________________________
Street____________________________________________________
__________________________________________
Signature of Attorney
City__________________________State___________Zip__________
__________________________________________
Phone (Include Area Code)___________________________________
Email Address of Attorney
Fax Number (Include Area Code) ______________________________
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
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 ___________________________________________________
Street ______________________________________________________
________________________________________________
Signature of Person Answering
Name ___________________________________________
City _____________________________State ______Zip _____________
Title ____________________________________________
Phone (Include Area Code) _____________________________________
Insurer: _____________________________________________________
(If Represented by Attorney)
Attorney _________________________________________
Street_______________________________________________________
Street ___________________________________________
City_____________________________State_______Zip______________
City ____________State__________Zip________________
Phone (include Area Code)______________________________________
Phone (Include Area Code)__________________________
ORDER (Completed by the deputy workers' compensation commissioner)
The allegations of the petition are found to be true.
The application is granted. Employer/Insurance Carrier shall pay claimant the requested vocational rehabilitation benefit
of $20.00/$100.00 per week for _________ weeks commencing when the training commences.
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___________________________________, _________________
Deputy Workers' Compensation Commissioner ____________________________________________________________________
Copies To: Attorney(s) at Law or Pro Se_____________________________ Attorney(s) at Law or Pro Se______________________
INSTRUCTIONS - BOTH PARTIES MUST USE THIS FORM
To Claimant:
1. Have your Vocational Rehabilitation Counselor complete the first part of this form.
2. You must attach to this form a copy of the physician's report which shows that the injury caused permanent disability which prevents you from returning to
gainful employment and the claimant’s confidential information sheet.
3. Deliver a copy of this form with the front page completed and the physician’s report to the employer by certified mail, return receipt requested or by personal
service as in civil actions (rule 876 IAC 4.7) and mail a copy to the employer’s attorney of record for this file if known (rule 876 IAC 4.13).
4. Complete the proof of service portion of the original of this form and deliver this entire form with the physician's report to the Division of Workers'
Compensation at 1000 East Grand Avenue, Des Moines, Iowa 50319-0209.
5. If you desire an evidentiary hearing, delete paragraph "4" of the petition and in its place enter "I request a hearing.” Rule 876 IAC 4.4.
6. The benefit is $20.00 per week, $100 for injuries after September 6, 2004, not to exceed 26 weeks.
To Employer/Insurance Carrier:
1. Enter the number of each paragraph of the petition which is denied in the space provided in paragraph "1" of the answer.
2. If you do not consent to the requested rehabilitation benefit, delete paragraph "2" of the answer.
3. If you desire an evidentiary hearing, delete paragraph "3" of the answer and in its place enter "I request a hearing. “ Rule 876 IAC 4.4.
4. Serve a copy of your answer to the claimant or claimant's attorney pursuant to rule 876 IAC 4.13.
5. Type or print the name and title of the person answering below the signature.
14-0009 (11-06)
American LegalNet, Inc.
www.FormsWorkflow.com
