Original Notice Petition Full Commutation Remaining Benefits 10 Wks Or More {14-0013}

You are required to file an answer within 20 days of the receipt of this document Payment Activity Report (PAR) shall match calculation below. 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. Upon receipt of the indicated sums and approval by the workers' compensation commissioner, I release and discharge the named employer and insurance 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 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 State of Iowa ______________________________ _________________________________________________________ Claimant Date _________________________________________________________ Fax Number of Attorney } 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 instrument 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. _____________________________________________________________ Employer/Insurance Carrier Date Email Address _________________________________________________ Fax Number ___________________________________________________ 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 Email Address _________________________________________________ Fax Number ___________________________________________________ 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 and claimant's confidential information sheet, 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 and 86.45(1) 14-0013 (Back) (09/14) American LegalNet, Inc. www.FormsWorkFlow.com