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BEFORE THE IOWA WORKERS COMPENSATION COMMISSIONER FILE NUMBER___ ORIGINAL NOTICE AND PETITION FORM NO. 100 (140005) 0809 (SEE INSTRUCTIONS ON REVERSE SIDE) Arbitration (86.14)Dependency (85.42, 43,
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Read all the instructions carefully before proceeding.
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Provide your personal information, including your name, address, and contact details.
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Specify the date and circumstances of the work-related injury or illness.
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Describe the body parts affected and the extent of the injury or illness.
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Explain how the injury or illness occurred and whether any witnesses were present.
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The www.iowaworkcomp.gov/original-notice-and-petition is needed by individuals who have experienced a work-related injury or illness in the state of Iowa. This form is to be submitted to the Iowa Workers' Compensation Commissioner to initiate a claim for workers' compensation benefits. Anyone who believes they are entitled to such benefits should complete and submit the original notice and petition.
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The original notice and petition is a legal document filed with the Iowa Workers' Compensation Commissioner to initiate a workers' compensation claim.
Employees who have sustained a work-related injury or illness and wish to seek benefits under workers' compensation law are required to file the original notice and petition.
The original notice and petition can be filled out electronically on the Iowa Workers' Compensation Commissioner's website or filled out manually and submitted via mail or in person.
The purpose of the original notice and petition is to officially notify the employer and the workers' compensation commissioner of a workplace injury or illness and to initiate the claims process.
The original notice and petition must include information such as details of the injury or illness, the date and location of the incident, the nature of the employment relationship, and the benefits being sought.
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