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

ADOBE ACROBAT

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NAME

Original Notice & Petition Concerning Vocational Rehabilitation Program Benefit

NUMBER

100B (14-0009)

EFFECTIVE

July 1, 2023

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 under the signature line for the attorney for the claimant or self-represented claimant.
5. Sign the form electronically on the fillable PDF or by hand after printing out the completed form.
6. Complete the proof of service portion on the original of this form and file the completed form, with the physician's report.
7. 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.
8. Attach the physician's report which supports the Petition.
9. Deliver a completed copy of the form to the employer by certified mail, return receipt requested, or by personal service as in civil actions and mail a copy to the employer’s attorney of record for this file, if known.

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.