Form 14-0163 — Claimant's Statement

ADOBE ACROBAT

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.

NAME

Claimant's Statement

NUMBER

14-0136

EFFECTIVE

July 1, 2023

OVERVIEW

DWC requires a claimant who is not represented by counsel to attach this completed and signed form with any proposed settlement documents.

DWC will use the information you give on this form when considering your proposed settlement.

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 form by providing the requested information by either typing it into the fillable PDF form or printing the form and writing legibly.
3. Sign the form and date your signature.
4. File the completed form with your settlement or commutation documents when you submit them to 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.