Form 14-0017 — Partial Commutation

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Name

Original Notice & Petition for Partial Commutation

Number

Form 14-0017

Effective

December 2023

Overview

This form is used to apply to DWC for a partial commutation of the claimant's remaining workers' compensation benefits.

Instructions

1. 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.
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 form by providing the requested information.
4. Provide applicant information.
5. The claimant, attorney for claimant, and employer/insurance carrier must sign the form.
6. File the completed form with the Iowa Division of Workers' Compensation (DWC).
7. Delivery of this form is to be by personal service as in civil actions or by certified mail, return receipt requested. (Rule 876 IAC 4.7)
8. A copy of this form with proof of delivery and the claimant's confidential statement must be filed with the DWC no later than 10 days after delivery upon the defendant(s).

eFiling on WCES

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

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

For more information about eFiling, click here.