Form 100D — Answer — Vocational Training & Education — 14-0012A

File: 
PDF icon Form 100D -- Vocational Training & Education -- Answer -- 14-0012A.pdf
Description: 

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NAME

Answer Concerning Application for Vocational Training & Education for Shoulder Injuries

NUMBER

100D (14-0012A)

EFFECTIVE

January 2020

OVERVIEW

A party completes and files this form in response to an Original Notice & Petition Concerning Application for Vocational Training & Education for Shoulder Injury under Iowa Code section 85.70(2) and Rule 876 IAC 4.50.

INSTRUCTIONS

  1. Download the form by clicking on the link above. Complete the form by typing the information into the fill-able fields on the PDF or by printing the form and handwriting in print the information on the printed form.
  2. Complete the caption by providing in the corresponding blank the:
    • Name of the claimant
    • Name of the employer
    • Name of any insurance carrier
    • Name(s) of any other defendant(s)
    • Any agency file number(s)

NOTE:  In some cases, there is not an insurance carrier (e.g., when the employer is self-insured) or any other defendant(s).

  1. Complete the Petition by filling out paragraphs 1, 2, 3, 4, and 5.
    • For Paragraph 2, provide only the address that is appropriate for you.
      • If you are the claimant, fill out only Paragraph 2(a).
      • If you are completing and filing the form on behalf of the employer and insurance carrier, fill out only Paragraphs 2(b) and 2(c).
      • If you are completing and filing the form on behalf of only the employer, fill out only Paragraph 2(b).
    • If there is not enough room under Paragraph 5, you may attach to the answer form a typewritten page of additional assertions.
  2. Provide your information.
    • If you are an attorney representing the respondent(s), provide your information under “Signature of Attorney for Respondent(s).”
    • If you are a representative of the employer/insurance carrier, provide your information under “Signature of Representative of Representative of or Self-Represented Respondent(s)."
    • If you are a self-represented claimant, provide your information under “Signature of Representative of Representative of or Self-Represented Respondent(s)."
  3. Sign the form (Rule 876 IAC 4.11).
    • If you are an attorney representing the defendant(s), sign on the “Signature of Attorney for Respondent(s)” line.
    • If you are a representative of the employer/insurance carrier, sign on the “Signature of Representative of Representative of or Self-Represented Respondent(s)" line.
    • If you are a self-represented claimant, sign on the “Signature of Representative of Representative of or Self-Represented Respondent(s)" line.
    • 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.
  4. Serve a copy to the opposing party or parties (Rule 876 IAC 4.13).

To download a PDF version of these instructions, 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.