Iowa > Workers Compensation
Original Notice And Petition And Order For Partial Commutation 9A - Iowa
| Original Notice And Petition And Order For Partial Commutation Form. This is a Iowa form and can be used in Workers Compensation . |
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FORM 9A - 14-0017 (11/03) BEFORE THE IOWA WORKERS COMPENSATION COMMISSIONER File No. ___________ (FRONT) SS# ___________________ ______________________________________________ ________________________ Claimant VS. (Injury Date) ORIGINAL NOTICE AND PETITION ______________________________________________ AND ORDER Employer FOR PARTIAL COMMUTATION ______________________________________________ Insurance Carrier 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. Claim activity report (form 2 or 2A) shall match calculation below. A. The undersigned makes Application for Partial Commutation of 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. Commutation of ________________________ Weeks for First part of remaining period Last part of remaining period Pro Rata 7. Commuted Value .................................... ________________ _____ X ____________________________ = $ ____________________ Factor Weekly Rate Commuted Value 8 Remainder After Commutation (if approved) _____________________ W eeks @ $ __________________ = $ ____________________ Total 9. 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. 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 ____________________________________________________________ ____________________________________________________________ Claimants Attorney Date Claimant Date 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. ____________________________________________________________ __ Employer/Insurance 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 Date 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 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 provided will be open for public inspection under Iowa Code 22.11 14-0017 BACK (11/03)
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