Effective July 22, 2019
This form is used to apply for deferment of the payment of filing fees that are required for some filings with the Iowa Division of Workers' Compensation (DWC).
Adobe Acrobat Reader
You must use Adobe Acrobat Reader to complete DWC forms electronically. Other PDF readers might not render the forms correctly. To get Adobe Acrobat Reader for free, click here.
- Download the form by clicking on the link above. Complete the form by providing the requested information.
- 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.
- Notarize the form.
- File the completed paper form with the DWC.
Mandatory Paper Filing
You must file the paper version of this completed form with the DWC under agency rules. Do not electronically file (eFile) this form.