Iowa Admin. Code r. 876-3.1

Current through Register Vol. 47, No. 6, October 2, 2024

Rule 876-3.1 - Forms

The following forms are available from the division of workers' compensation for use in matters under the jurisdiction of the workers' compensation commissioner. Insurance carriers, self-insured employers, or their adjusting agents may reproduce the forms in which event the name, address, telephone number, and identification number may be imprinted. The current revision of the form must be used. Each form is identified by a form number. This form number follows each form name listed below and is used when requesting that specific form.

(1)First report of injury (FROI). The FROI contains general information concerning the employee, the employer and the claimed injury. A FROI is to be filed whether or not an adjudication or admission of liability for the injury exists and is to be filed as provided in Iowa Code section 86.11 and 876-Chapter 11. The FROI is to be filed when demanded by the commissioner pursuant to Iowa Code section 86.12 and when an employer is served with an original notice and petition that alleges an injury for which a FROI has not been filed. If an original notice and petition alleges multiple injury dates, only one FROI should be filed, and the date of injury reported should be the date the reporter uses when adjusting the claim.

(2)Subsequent report of injury (SROI).

a. The SROI provides for filing of notice of commencement of payments, correcting erroneous claim information, supplying additional information, denying compensability, agreeing to the weekly benefit rate and agreeing to make payments under the Workers' Compensation Act, reporting the status ofa claim, or recording benefits paid. Notice of commencement of payments shall be filed within 30 days of the first payment. When liability on a claim is denied, a letter shall be sent to claimant stating reasons for denial. The SROI shall also be filed when compensation is terminated or interrupted. Medical data supporting the action taken shall be filed when temporary total disability or temporary partial disability exceeds 13 weeks or when the employee sustains a permanent disability.

b. The employer and insurance carrier who are required to file medical data shall file the medical data in WCES. The employer or insurance carrier or the employer's or insurance carrier's agent shall register in WCES to file the medical data. The filer will receive a status update for the information the filer submits based upon the status the filer selects and for which the filer is approved in WCES.

(3)Form No. 2A-claim activity report. (Form No. 14-0003) Reserved.

(4)Form No. 2B-supplemental information report. (Form No. 14-9999) Reserved.

(5)Form No. 12-waiver on account of physical defect. (Form No. 14-0029) Reserved.

(6)Form-rehabilitation referral and acknowledgment. (Form No. 309-5051) Reserved.

(7)Form-original notice and petition. The following forms are types of original notice and petition: original notice and petition-Form 100 (Form No. 14-0005); original notice and petition concerning application for independent medical examination-Form 100A (Form No. 14-0007); answer and order concerning application for independent medical examination-Form 100A (Form No. 14-0007A); original notice and petition concerning vocational rehabilitation program benefit-Form 100B (Form No. 14-0009); answer concerning vocational rehabilitation program benefit-Form 100B (Form No. 14-0009A); original notice, petition concerning application for alternate medical care-Form 100C (Form No. 14-0011); answer concerning application for alternate medical care-Form 100C (Form No. 14-0011A); original notice and petition concerning application for vocational training and education-Form 100D (Form No. 14-0012); answer concerning application for vocational training and education-Form 100D (Form No. 14-0012A); original notice and petition for full commutation of all remaining benefits of ten weeks or more 876 IAC 6.2(6)-Form 9 (Form No. 14-0013); and original notice and petition and order for partial commutation-Form 9A (Form No. 14-0017). See rule 876-4.6 (85,86,17A) for further descriptions.

(8)Form-subpoena. (Form No. 14-0035) This form is the witness subpoena, which is used to require a witness to appear and testify, and the Subpoena Duces Tecum, which is used to require a witness to appear and to bring specified books and records.

(9)Form-corporate officer exclusion. (Form No. 14-0061) This form is the corporate officer exclusion which is used for corporate officers to reject workers' compensation or employers' liability.

(10)Form-attorney lien. (Form No. 14-0039) Reserved.

(11)Form-application and consent order for payment of benefits. (Form No. 14-0037) This form is the application and consent order for payment of benefits under Iowa Code section 85.21 which is used by an employer or an insurance carrier to pay weekly and medical benefits without admitting liability and to be able to seek reimbursement from another carrier or employer.

(12) Reserved.

(13)Form-dispute resolution conference report. (Form No. 14-0041) This form is the dispute resolution conference report which is used to provide information for a dispute resolution pursuant to rule 876-4.40 (73GA,ch1261).

(14)Form-forms order blank. (Form No. 14-0031) Reserved.

(15)Form-agreement for settlement. (Form No. 14-0021) Reserved.

(16)Form-contested case settlement. (Form No. 14-0025) Reserved.

(17)Form-authorization for release of information regarding claimants seeking workers' compensation benefits. (Form No. 14-0043) This form is used for the release of information concerning an employee's physical or mental condition relative to a workers' compensation claim.

(18)Form No. 9-original notice and petition for commutation of all remaining benefits of ten weeks or more 876 IAC 6.2(6). (Form No. 14-0013) This form contains data relevant to benefits paid and those to be paid by commutation when all unaccrued benefits are due. Signatures of the parties are necessary. Approval by the workers' compensation commissioner or a deputy workers' compensation commissioner is necessary. The form contains language of release.

(19)Form No. 9A-original notice and petition for partial commutation. (Form No. 14-0017) This form contains the same data and requirements as Form No. 9. However, all remaining benefits are not commuted. No language of release is contained.

(20)Form-prehearing conference report. (Form No. 14-0049) Reserved.

(21)Form-agreement for settlement. (Form No. 14-0021) This form is used to file an agreement for settlement pursuant to Iowa Code section 85.35(2).

(22)Form-compromise settlement. (Form No. 14-0025) This form is used to file a compromise settlement pursuant to Iowa Code section 85.35(3).

(23)Form-combination settlement. (Form No. 14-0159) This form is used to file a combination settlement pursuant to Iowa Code section 85.35(4).

(24)Form-contingent settlement. (Form No. 14-0161) This form is used to file a contingent settlement pursuant to Iowa Code section 85.35(5).

(25)Form-claimant's statement. (Form No. 14-0163) This form is used for any type of settlement when the claimant is not represented by an attorney.

(26)Form-application to defer payment of filing fees, financial affidavit and order. (Form No. 14-0075) This form is used to request a deferral of payment of filing fees. This form is not initially filed through WCES.

(27)Form-nonelection of workers' compensation or employers' liability coverage. (Form No. 14-0175) This form is used for exclusion from liability coverage pursuant to Iowa Code section 87.22.

(28)Form-shorthand reporter identification form. (Form No. 14-0178) This form is used to identify the official shorthand reporter and custodian of the notes for a hearing.

(29)Form-request for waiver of the mandatory use of WCES. (Form No. 14-0176) This form is used by a self-represented party to request a waiver from those rules requiring filing in WCES and allows a party to file and serve documents in paper form.

Iowa Admin. Code r. 876-3.1

Amended by IAB December 20, 2017/Volume XL, Number 13, effective 1/24/2018

Amended by IAB July 31, 2019/Volume XLII, Number 3, effective 7/10/2019

Amended by IAB February 8, 2023/Volume XLV, Number 16, effective 3/15/2023