Iowa > Workers Compensation
Original Notice And Petition And Order For Commutation Of All Remaining Benefits Of 10 Weeks Or More 9 - Iowa
| Original Notice And Petition And Order For Commutation Of All Remaining Benefits Of 10 Weeks Or More Form. This is a Iowa form and can be used in Workers Compensation . |
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FORM 9 - 14-0013 (7/99) BEFORE THE IOWA WORKERS COMPENSATION COMMISSIONER File No._____________ front SS# _________________________________________________________________ ________________________ Claimant VS. (Injury Date) ORIGINAL NOTICE AND PETITION______________________________________________ AND ORDER Employer FOR COMMUTATION OF ALL REMAINING BENEFITS______________________________________________ OF 10 WEEKS OR MORE 876 IAC 6.2(6) Insurance Carrier To Employer and Insurance carrier: You are notified that an action for commutation of all remaining benefits has been commence d before the workerscompensation commissioner seeking relief under the chapters of the Iowa Code relating to workers compensation, occupational di sease andoccupational hearing loss (Chapter 85, 85A, 85B, 86 and 87). A hearing will be held in the judicial district wherein the injury occurred. Whenapplicable, the parties will be notified by the workers compensation commissioner of the time and place of the prehearing conf erence and hearing. Youare 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. Claim activity report (form 2 or 2A) shall match calculation below. A. The undersigned makes Application for Full Commutation of all remaining benefits in the above entitled case and represents:1.As a result of the compensable injury or death, claimant has suffered a permanent disability equal to _______ % of the ____ ________ 2. Total Entitlement ................... Temporary Partial Healing Period Permanent/Death Weeks ________________ Weeks _______________ Weeks _______________ $ ____________________ $ ____________________ Amount Paid ________________ Rate _________________ Rate ________________ $ _______________ Total 3. Paid to Date .......................... Temporary Partial Healing Period Permanent/Death Weeks ________________ Weeks ________________ Weeks ______________ $ _____________________$ ___________________ Amount Paid ________________ Thru ___________________Thru _________________ $_______________ Date Date Total 4. Accrued-Not Paid ................... Temporary/Partial Healing Period Permanent/Death Weeks ________________ Weeks _________________Weeks _______________ $ ______________________$ ____________________ Amount Paid ________________ Thru ____________________Thru _________________$______________ Date Date Total 5. Remainder .............................................. _____________________ Weeks @ $ ___________________ Total $ _______________ 6. Commuted Value .................................... _____________________ X ____________________________ $ _________ ___________ Factor Weekly Rate Commuted Value 7. Other Terms ________________________________________________________________________________________________________________ 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 <<<<<<<<<********>>>>>>>>>>>>> 2D.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. Upon receipt ofthe indicated sums and approval by the workers compensation commissioner, I release and discharge the named employer and insur ance carrier from all liability under the Iowa Workers Compensation Law which is now in existence or may exist in the future on account of the indicated injury. I consent to the degree of disability and the granting of the commutation. In the event the employer consents to the commutati on, I waive any provision concerningcontested cases as provided in Chapter 17A or otherwise. If I am not represented, I waive my right to an attorney ____________________________________________________________ _______________________________________________________ Claimants Attorney Date Claimant Date State of Iowa ______________________________ } SS On this _______________ day of ______________________________ , ______ before me personally appeared the above claimant to me known to be the identical person named in and who executed the foregoing instrumen t and acknowledged that the document has been read and executed as a voluntary act. ___________________________________________________________ Notary Public E. EMPLOYER 1. 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. __________________________________________________________ Emr/Insurpalnocyee Carrier Date 2. 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 DateThe foregoing Application for Commutation is approved and the relief sought is granted ___________________ , _____. ____________________________________________ Iowa Workerspensation C Com ommissioner 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 IAC 4.7. 2. A copy of this form with proof of delivery, 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 MOINES, IOWA 50319-0209 (515) 281- 5387 The information pro
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