Form 100C (14-0011) — Original Notice & Petition Concerning Application for Alternate Care

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NAME

Original Notice & Petition Concerning Application for Alternate Care

NUMBER

100C (14-0011)

EFFECTIVE

July 1, 2023

OVERVIEW

Alternate care is the only issue that can be considered when you start a case by filing this form.

An attorney representing the claimant or self-represented claimant must file this completed form to start a contested case proceeding on the issue of alternate care.

This procedure is not available if the employer disputes liability on the claim generally. If liability is disputed, this case will be dismissed without prejudice. Disputed cases should be commenced under Iowa Administrative Code rule 876—4.1.

The information provided in this case will be open for public inspection under Iowa Code section 22.1.

INSTRUCTIONS

1. Download the fill-able PDF 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.
2. 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). 
3. Complete the Petition by filling out paragraphs 1, 2, 3, 4, 5, 6, 8, 9, and 11.
4. Provide your information under the signature line.
5. Sign the form electronically or by hand after printing out the completed form.
6. If you use an electronic signature under agency rules, lock or "flatten" the PDF document after completing the form fields to ensure the document can be viewed on all devices and to prevent other users from manipulating or editing the information.
7. Complete the proof of service portion on the original of this form.
8. Electronically file (eFile) the form on the Workers' Compensation Electronic System (WCES).
9. Deliver a completed copy of the form to the employer by certified mail, return receipt requested, or by personal service as in civil actions and mail a copy to the employer’s attorney of record for this file, if known.

EFILING ON WCES

DWC requires parties and attorneys to electronically file (eFile) documents on the Workers' Compensation Electronic System (WCES) in contested case proceedings.

You must eFile on WCES documents, such as this completed form, unless the DWC has granted you an eFiling exception.

For more information about eFiling, click here.