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Application for Payment of Benefits
July 22, 2019
This form is used by an employer or an insurance carrier to pay weekly and medical benefits under Iowa Code section 85.21 without admitting liability and to be able to seek reimbursement from another carrier or employer.
- 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, 4, 5, 6, and 7.
- A representative of the employer or insurance carrier signs the form.
- File the completed form with the DWC.
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.