Iowa Admin. Code r. 876-3.1 - Forms
The following forms are available from the division of workers' compensation for use in matters under the jurisdiction of the workers' compensation commissioner. Insurance carriers, self-insured employers, or their adjusting agents may reproduce the forms in which event the name, address, telephone number, and identification number may be imprinted. The current revision of the form must be used. Each form is identified by a form number. This form number follows each form name listed below and is used when requesting that specific form.
(1)
First report of injury (FROI). The FROI contains general
information concerning the employee, the employer and the claimed injury. A
FROI is to be filed whether or not an adjudication or admission of liability
for the injury exists and is to be filed as provided in Iowa Code section 86.11 and 876-Chapter 11. The FROI is to be filed when demanded by the commissioner
pursuant to Iowa Code section 86.12 and when an employer is served with an
original notice and petition that alleges an injury for which a FROI has not
been filed. If an original notice and petition alleges multiple injury dates,
only one FROI should be filed, and the date of injury reported should be the
date the reporter uses when adjusting the claim.
(2)
Subsequent report of injury
(SROI).
a. The SROI provides for
filing of notice of commencement of payments, correcting erroneous claim
information, supplying additional information, denying compensability, agreeing
to the weekly benefit rate and agreeing to make payments under the Workers'
Compensation Act, reporting the status ofa claim, or recording benefits paid.
Notice of commencement of payments shall be filed within 30 days of the first
payment. When liability on a claim is denied, a letter shall be sent to
claimant stating reasons for denial. The SROI shall also be filed when
compensation is terminated or interrupted. Medical data supporting the action
taken shall be filed when temporary total disability or temporary partial
disability exceeds 13 weeks or when the employee sustains a permanent
disability.
b. The employer and
insurance carrier who are required to file medical data shall file the medical
data in WCES. The employer or insurance carrier or the employer's or insurance
carrier's agent shall register in WCES to file the medical data. The filer will
receive a status update for the information the filer submits based upon the
status the filer selects and for which the filer is approved in WCES.
(3)
Form No. 2A-claim
activity report. (Form No. 14-0003) Reserved.
(4)
Form No. 2B-supplemental
information report. (Form No. 14-9999) Reserved.
(5)
Form No. 12-waiver on account of
physical defect. (Form No. 14-0029) Reserved.
(6)
Form-rehabilitation referral and
acknowledgment. (Form No. 309-5051) Reserved.
(7)
Form-original notice and
petition. The following forms are types of original notice and
petition: original notice and petition-Form 100 (Form No. 14-0005); original
notice and petition concerning application for independent medical
examination-Form 100A (Form No. 14-0007); answer and order concerning
application for independent medical examination-Form 100A (Form No. 14-0007A);
original notice and petition concerning vocational rehabilitation program
benefit-Form 100B (Form No. 14-0009); answer concerning vocational
rehabilitation program benefit-Form 100B (Form No. 14-0009A); original notice,
petition concerning application for alternate medical care-Form 100C (Form No.
14-0011); answer concerning application for alternate medical care-Form 100C
(Form No. 14-0011A); original notice and petition concerning application for
vocational training and education-Form 100D (Form No. 14-0012); answer
concerning application for vocational training and education-Form 100D (Form
No. 14-0012A); original notice and petition for full commutation of all
remaining benefits of ten weeks or more 876 IAC 6.2(6)-Form 9 (Form No.
14-0013); and original notice and petition and order for partial
commutation-Form 9A (Form No. 14-0017). See rule 876-4.6 (85,86,17A) for further
descriptions.
(8)
Form-subpoena. (Form No. 14-0035) This form is the witness
subpoena, which is used to require a witness to appear and testify, and the
Subpoena Duces Tecum, which is used to require a witness to appear and to bring
specified books and records.
(9)
Form-corporate officer exclusion. (Form No. 14-0061) This form
is the corporate officer exclusion which is used for corporate officers to
reject workers' compensation or employers' liability.
(10)
Form-attorney lien. (Form No.
14-0039) Reserved.
(11)
Form-application and consent order for payment of benefits. (Form No.
14-0037) This form is the application and consent order for payment of
benefits under Iowa Code section 85.21 which is used by an employer or an
insurance carrier to pay weekly and medical benefits without admitting
liability and to be able to seek reimbursement from another carrier or
employer.
(12) Reserved.
(13)
Form-dispute resolution
conference report. (Form No. 14-0041) This form is the dispute
resolution conference report which is used to provide information for a dispute
resolution pursuant to rule 876-4.40 (73GA,ch1261).
(14)
Form-forms order blank. (Form
No. 14-0031) Reserved.
(15)
Form-agreement for settlement.
(Form No. 14-0021) Reserved.
(16)
Form-contested case settlement.
(Form No. 14-0025) Reserved.
(17)
Form-authorization for release
of information regarding claimants seeking workers' compensation benefits.
(Form No. 14-0043) This form is used for the release of information
concerning an employee's physical or mental condition relative to a workers'
compensation claim.
(18)
Form No. 9-original notice and petition for commutation of all
remaining benefits of ten weeks or more 876 IAC 6.2(6). (Form No.
14-0013) This form contains data relevant to benefits paid and those
to be paid by commutation when all unaccrued benefits are due. Signatures of
the parties are necessary. Approval by the workers' compensation commissioner
or a deputy workers' compensation commissioner is necessary. The form contains
language of release.
(19)
Form No. 9A-original notice and petition for partial commutation. (Form
No. 14-0017) This form contains the same data and requirements as Form
No. 9. However, all remaining benefits are not commuted. No language of release
is contained.
(20)
Form-prehearing conference report. (Form No. 14-0049)
Reserved.
(21)
Form-agreement for settlement. (Form No. 14-0021) This form is
used to file an agreement for settlement pursuant to Iowa Code section
85.35(2).
(22)
Form-compromise settlement. (Form No. 14-0025) This form is
used to file a compromise settlement pursuant to Iowa Code section
85.35(3).
(23)
Form-combination settlement. (Form No. 14-0159) This form is
used to file a combination settlement pursuant to Iowa Code section
85.35(4).
(24)
Form-contingent settlement. (Form No. 14-0161) This form is
used to file a contingent settlement pursuant to Iowa Code section
85.35(5).
(25)
Form-claimant's statement. (Form No. 14-0163) This form is
used for any type of settlement when the claimant is not represented by an
attorney.
(26)
Form-application to defer payment of filing fees, financial affidavit
and order. (Form No. 14-0075) This form is used to request a deferral
of payment of filing fees. This form is not initially filed through
WCES.
(27)
Form-nonelection
of workers' compensation or employers' liability coverage. (Form No.
14-0175) This form is used for exclusion from liability coverage
pursuant to Iowa Code section 87.22.
(28)
Form-shorthand reporter
identification form. (Form No. 14-0178) This form is used to identify
the official shorthand reporter and custodian of the notes for a
hearing.
(29)
Form-request
for waiver of the mandatory use of WCES. (Form No. 14-0176) This form
is used by a self-represented party to request a waiver from those rules
requiring filing in WCES and allows a party to file and serve documents in
paper form.
Notes
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