ADOBE ACROBAT READER
You must use Adobe Acrobat Reader to complete Iowa Division of Workers' Compensation (DWC) forms electronically. Other PDF readers might not render the forms correctly. To get Adobe Acrobat Reader for free, click here(link is external).
NAME
Claimant's Statement
NUMBER
14-0163
EFFECTIVE
July 2012
OVERVIEW
This form must be used when a the injured worker (claimant) is not represented by an attorney.
The unrepresented claimant must complete, certify, and sign the claimant's statement form. The parties must then include the completed claimant's statement with the settlement or commutation documents submitted for agency approval.
The information provided will be open for public inspection under Iowa Code sections 22.1 and 86.45(1).
INSTRUCTIONS
- 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 and 2.
- The parties and their attorneys sign the form.
- File the completed form with the DWC.
DWC APPROVAL OF SETTLEMENT DOCUMENTS
DWC must approve settlements of workers' compensation claims. For more information, click here.
EFILING ON WCES
DWC requires the electronic filing (eFiling) of settlement documents, such as this completed form, on the Workers' Compensation Electronic System (WCES).
For more information about eFiling, click here.
EFILING TIPS: SETTLEMENT DOCUMENTS
DWC has developed tips for eFiling settlement documents on WCES. To view the tips for eFiling settlement documents on WCES, click here.