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Name
Original Notice & Petition Concerning Vocational Training & Education for Shoulder Injuries
Number
100D (14-0012A)
Effective
December 2019
Overview
This form is used to appeal an action relating to vocational education and training program under Iowa Code section 85.70(2) and Rule 876 IAC 4.50.
This form may be filed by the employee, employer, or insurance carrier.
Instructions
- 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.
- 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).
- Complete the form by filling out paragraphs 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.
- The party or party's attorney signs the form. 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.
- File the completed form with the DWC.
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.