Form 100 — Original Notice and Petition — 14-0005

File: 
PDF icon Form 100 -- Original Notice & Petition -- 2023.03.pdf
Description: 

Adobe Acrobat

You must use Adobe Acrobat Reader to complete Iowa Division of Workers' Compensation (DWC) forms electronically. Other PDF readers might not render the forms correctly. To get Adobe Acrobat Reader for free, click here.

Name

Original Notice & Petition

Number

100 (14-0005)

Overview

A party must use this form to initiate a contested case proceeding before the Iowa Workers' Compensation Commissioner, including:

  • Arbitration under Iowa Code section 86.14
  • Review-reopening under Iowa Code section 86.14
  • Medical benefits under Iowa Code section 85.27
  • Death benefits under Iowa Code sections 85.28, 85.29, and 85.31
  • Dependency under Iowa Code section 85.42, 85.43, and 85.44
  • Equitable apportionment under Iowa Code section 85.43
  • Second Injury Fund under Iowa Code section 85.63 et seq.
  • Other (in which case, you must attach a petition to the form when filing it)

Filing Fee

A person must pay the fee for filing a petition at the time of filing.

You may pay the filing fee online through the Workers' Compensation Electronic System (WCES) at the time of electronic filing (eFiling).

Effective March 15, 2023:

The filing fee changes from $100 to $125.

Instructions

To complete the form, you may do one of the following:

  • Type information into each applicable blank of the fillable PDF form and after you finish, print the completed form; or
  • Print the blank form and hand-write information into the applicable blanks. If you choose to complete the form by handwriting, you must print. Do not use cursive.

To complete this form:

  1. On the left-hand side of the caption, type the name of the claimant, employer, and insurance carrier.
  2. On the right-hand side of the caption, indicate the type of case and issue(s).
  3. Under Paragraph 1, provide the employer's address.
  4. Under Paragraph 2, provide the insurance carrier's address (if the employer is not self-insured).
  5. Under Paragraph 3, provide the alleged date(s) of injury.
  6. Under Paragraph 4, describe how the alleged injury occurred.
  7. Under Paragraph 5, identify the body part(s) alleged to have been affected or disabled by the alleged injury.
  8. Under Paragraph 6, indicate whether voluntary weekly payments of benefits have been made.
  9. Under Paragraph 7, provide the date(s) on which the claimant was disabled.
  10. Under Paragraph 8, described the nature and extent of permanent disability (if known).
  11. Under Paragraph 9, describe the amount of any medical expenses under Iowa Code section 85.27 and with whom the expenses were incurred.
  12. Under Paragraph 10, state the dispute in the case.
  13. Under Paragraph 11, identify the county and judicial district where the alleged injury is alleged to have occurred. If the alleged injured is alleged to have occurred outside the State of Iowa, write Polk.
  14. Under Paragraph 12, identify the judicial district in which the claimant and defendant(s) agree DWC may hold the hearing.
  15. Under Paragraph 13, if the claimant is seeking Second Injury Fund benefits:
    • In Blank "a," identify the date of the alleged first loss.
    • In Blank "b," identify the body part alleged to be affected by the first loss.
    • In Blank "c," describe how the body part alleged to be affected by the first loss was affected.
  16. If the case involves the death of an employee:
    • Under Paragraph 14, provide the name of the deceased employee.
    • Under Paragraph 15, describe the relationship between the claimant and the deceased employee.
    • Under Paragraph 16, identify the date of death of the employee.
    • Under Paragraph 17, provide the amount in expenses for the deceased employee's funeral.
    • Under Paragraph 18, identify any dependents and state the dependents' relationship to the deceased employee.
  17. Provide the information for the attorney representing the claimant or, if the claimant is self-represented, the information for the claimant.
  18. If you use an electronic signature under agency rules, lock or "flatten" the PDF document after completing the form fields to ensure the document can be viewed on all devices and to prevent other users from manipulating or editing the information.
  19. The attorney for the claimant or self-represented claimant must sign the petition under agency rules.

Once filed, the Original Notice & Petition must be served in accordance with agency rules. To view agency rules, click here.

eFiling on WCES

The Iowa Division of Workers' Compensation (DWC) requires parties and attorneys to electronically file (eFile) documents on the Workers' Compensation Electronic System (WCES) in contested case proceedings.

You must eFile on WCES documents, such as this completed form, unless the DWC has granted you an eFiling exception.

For more information about eFiling, click here.