ADOBE ACROBAT
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NAME
Original Notice & Petition for Full Commutation of Benefits
NUMBER
Form 14-0013
EFFECTIVE
December 2023
OVERVIEW
This form is used to apply with the Iowa Division of Workers' Compensation (DWC) for a full commutation of the claimant's remaining workers' compensation benefits.
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 providing the requested information.
- The claimant, attorney for claimant, a representative of the employer/insurance carrier, and attorney for defendant(s) must sign the form.
- Electronically file (eFile) the completed form with DWC on the Workers' Compensation Electronic System (WCES).
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.