Form 100B — Original Notice & Petition — Vocational Rehabilitation Program Benefit — 14-0009

Description: 

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Name

Original Notice & Petition Concerning Vocational Rehabilitation Program Benefit

Number

100B (14-0009)

Effective

July 22, 2019

Overview

An attorney representing the claimant or a self-represented claimant must file this completed form to apply for the vocational rehabilitation program benefit under Iowa Code section 85.70(1).

This form is not used for any reason relating to the vocational training and education program under Iowa Code section 85.70(2).

The information provided in this case will be open for public inspection under Iowa Code section 22.1.

Instructions

  1. Download the fill-able PDF 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). 
  3. Complete the Petition by filling out paragraphs 1, 2, 3, 4, 6, 7, 8, and 9. This includes obtaining the signature of the claimant's vocational rehabilitation counselor.
  4. Provide your information.
    • If you are an attorney representing the claimant, provide your information under “Signature of Attorney for Claimant.”
    • If you are a self-represented claimant, provide your information under “Signature of Self-Represented Claimant.”
  5. Sign the form (Rule 876 IAC 4.11).
    • If you are an attorney representing the claimant, sign on the “Signature of Attorney for Claimant” line.
    • If you are a self-represented claimant, sign on the “Signature of Self-Represented Claimant” line.
  6. Attach the physician's report which supports the Petition.
  7. Deliver a completed copy of the form to the employer by certified mail, return receipt requested, or by personal service as in civil actions (Rule 876 IAC 4.7) and mail a copy to the employer’s attorney of record for this file, if known (Rule 876 IAC 4.13).
  8. Complete the proof of service portion on the original of this form and file the completed form, with the physician's report.

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.