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Form 100 (14-0005) — Original Notice & Petition

File: 
PDF icon Original Notice & Petition -- Form 100 (14-0005).pdf
Description: 

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Name

Original Notice & Petition

Number

100 (14-0005)

Effective

July 1, 2023

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 10A.317
  • Review-reopening under Iowa Code section 10A.317
  • 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 is $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, insurance carrier (if applicable), and any other defendants.
  2. On the right-hand side of the caption,type the DWC file number(s) for the case (if known).
  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 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.
  8. Under Paragraph 6, identify the body part(s) and condition(s) alleged to have been affected or disabled by the alleged injury by checking the corresponding box(es) and identify the body part(s) (e.g., "right," "left," or "both" for the listed body parts and for "body as a whole" the impacted body part such as "back," "neck," "mental health," etc.).
  9. Under Paragraph 7, provide the date(s) for the start and end of the period(s) of time during which the claimant was disabled.
  10. Under Paragraph 8, describe identify the disputed issue(s) in the case and provide information for the type(s) of benefits the claimant is seeking.
  11. Under Paragraph 9,  identify the judicial district in which the petitioner wants the respondent(s) to agree DWC may hold the hearing.
  12. Under Paragraph 10, 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.
  13. Under Paragraph 11, if the case involves the death of an employee:
    • In Blank "a," provide the name of the deceased employee.
    • In Blank "b," identify the date of death of the deceased employee.
    • In Blank "c," describe the relationship between the claimant and the deceased employee.
    • In Blank "d," provide the amount in expenses for the deceased employee's funeral.
    • In Blank "e," identify any dependents and state the dependents' relationship to the deceased employee.
  14. Provide the information for the attorney representing the petitioner or, if the petitioner is self-represented, the information for the petitioner.
  15. 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.
  16. The attorney for the petitioner or the self-represented petitioner 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

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.