Effective July 22, 2019
This form is used to apply for an exception to mandatory electronic filing (eFiling) on the Workers' Compensation Electronic System (WCES) 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 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 through 4.
- Provide applicant information.
- If the applicant is an attorney, the applicant provides information under "Signature of Attorney."
- If the applicant is a self-represented party, the applicant provides information under "Signature of Self-Represented Party."
- Sign the form.
- If the applicant is an attorney, the applicant signs on the line above "Signature of Attorney."
- If the applicant is a self-represented party, the applicant signs on the line above "Signature of Self-Represented Party."
- File the completed form with the DWC.
The DWC requires eFiling on WCES in contested case proceedings.
For more information about eFiling, click here.