CHAPTER 3
FORMS
[Prior to 9/24/86 see Industrial Commissioner[500]]
[Prior to 1/29/97 see Industrial Services Division[343]]
[Prior to 7/29/98 see Industrial Services Division[873]Ch 3]
876—3.1(17A) 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.
	3.1(1) First report of injury. The first report of injury (FROI) contains general information concerning the employee, the employer and the claimed injury. It 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 first report of injury 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 first report has not been filed. If an original notice and petition alleges multiple injury dates, only one first report of injury should be filed, and the date of injury reported should be the date the reporter uses when adjusting the claim.
	3.1(2) Subsequent report of injury (SROI). The subsequent report of injury (SROI) provides for filing of notice of commencement of payments, correcting erroneous claim information, supplying additional information, denying compensability, agreeing to rate and agreeing to make payments under the Workers’ Compensation Act, reporting the status of a 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 subsequent report of injury (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. In the event the transmission of a subsequent report of injury (SROI) contains errors (TE), the errors shall be corrected within 15 days of the date of notification by the agency.
	3.1(3) Form No.	2A—claim activity report. (Form No.	14-0003) Rescinded IAB 3/6/02, effective 4/10/02.
	3.1(4) Form No.	2B—supplemental information report. (Form No.	14-9999) Rescinded IAB 3/6/02, effective 4/10/02.
	3.1(5) Form No.	12—waiver on account of physical defect. (Form No.	14-0029) Rescinded IAB 10/25/06, effective 11/29/06.
	3.1(6) Form—rehabilitation referral and acknowledgment. (Form No.	309-5051) This form contains information relevant to referral of an employee for consideration of rehabilitation services under the jurisdiction of RESB.
	3.1(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, petition, answer and order concerning independent medical examination—Form 100A (Form No.	14-0007); original notice, petition, answer and order concerning vocational rehabilitation program benefit—Form 100B (Form No.	14-0009); original notice, petition, and answer concerning application for alternate medical care—Form 100C (Form No.	14-0011); 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); checklist for full commutation (Form No.	14-0015); original notice and petition and order for partial commutation—Form 9A (Form No.	14-0017); and checklist for partial commutation (Form No.	14-0019). See rule 876—4.6(85,86,17A) for further descriptions.
	3.1(8) Form No.	15—subpoena. (Form No.	14-0035) This form is the witness subpoena which is used to require a witness to appear and testify. Form No.	14-0033 is the Subpoena Duces Tecum which is used to require a witness to appear and to bring specified books and records.
	3.1(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.
	3.1(10) Form—attorney lien. (Form No.	14-0039) Rescinded IAB 3/6/02, effective 4/10/02.
	3.1(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.
	3.1(12) Rescinded IAB 1/29/97, effective 3/5/97.
	3.1(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).
	3.1(14) Form—forms order blank. (Form No.	14-0031) This form is the forms order blank which is used to order other forms used by the agency.
	3.1(15) Form—agreement for settlement. (Form No.	14-0021) Rescinded IAB 10/25/06, effective 11/29/06.
	3.1(16) Form—contested case settlement. (Form No.	14-0025) Rescinded IAB 10/25/06, effective 11/29/06.
	3.1(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.
	3.1(18) Form No.	9—original notice and petition and order 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 commissioner is necessary. The form contains language of release.
	3.1(19) Form No.	9A—original notice and petition and order 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.
	3.1(20) Form—prehearing conference report. (Form No.	14-0049) Rescinded IAB 10/25/06, effective 11/29/06.
	3.1(21) Form—agreement for settlement. (Form No 14-0021) This form is used to file an agreement for settlement pursuant to Iowa Code Supplement section 85.35(2).
	3.1(22) Form—compromise settlement. (Form No.	14-0025) This form is used to file a compromise settlement pursuant to Iowa Code Supplement section 85.35(3).
	3.1(23) Form—combination settlement. (Form No.	14-0159) This form is used to file a combination settlement pursuant to Iowa Code Supplement section 85.35(4).
	3.1(24) Form—contingent settlement. (Form No.	14-0161) This form is used to file a contingent settlement pursuant to Iowa Code Supplement section 85.35(5).
	3.1(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.
These rules are intended to implement Iowa Code section 17A.3(1)“b.”
[Emergency filed and effective 9/19/75—published 10/6/75]
[Filed 11/17/75, Notice 10/6/75—published 12/1/75, effective 1/5/76]
[Filed emergency 6/25/76—published 7/12/76, effective 7/1/76]
[Filed emergency 8/31/79—published 9/19/79, effective 8/31/79]
[Filed emergency 8/31/79—published 9/19/79, effective 10/24/79]
[Filed emergency 6/18/82—published 7/7/82, effective 7/1/82]
[Filed emergency 6/26/86—published 7/16/86, effective 7/1/86]
[Filed emergency 8/25/86—published 9/10/86, effective 8/25/86]1
[Editorially transferred from [500] to [343], IAC Supp. 9/24/86, see IAB 7/16/86]
[Filed 8/26/94, Notice 7/20/94—published 9/14/94, effective 10/19/94]
[Filed 1/10/97, Notice 12/4/96—published 1/29/97, effective 3/5/97]
[Filed emergency 7/1/98—published 7/29/98, effective 7/1/98]
[Filed 9/4/98, Notice 7/29/98—published 9/23/98, effective 10/28/98]
[Filed 2/15/02, Notice 1/9/02—published 3/6/02, effective 4/10/02]◊
[Filed 4/12/02, Notice 3/6/02—published 5/1/02, effective 7/1/02]
[Filed 11/4/05, Notice 9/14/05—published 11/23/05, effective 1/1/06]
[Filed 10/5/06, Notice 8/30/06—published 10/25/06, effective 11/29/06]
◊	Two or more ARCs
1	See IAB Industrial Services, Division of [343]