Forms

The Iowa Division of Workers' Compensation (DWC) requires the use of agency forms for certain filings.

Failure to use the correct form may result in your filing being rejected.

This page contains links to help you find and use current DWC forms.

Adobe Acrobat

You must use Adobe Acrobat to complete DWC forms electronically. Other PDF readers might not render the forms correctly. To get Adobe Acrobat Reader for free, click here.

Index

To view forms under a category, click on the corresponding link below:

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To search all DWC forms and publications, click here.

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Pleadings

Arbitration

Form 100 — Original Notice & Petition

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Independent Medical Examination (IME)

Form 100A — Original Notice & Petition Concerning Application for IME (14-0007)

Form 100A — Answer to Petition Concerning Application for IME (14-0007A)

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Vocational Rehabilitation Program Benefit Under Iowa Code Section 85.70(1)

Form 100B — Original Notice & Petition Concerning Vocational Rehabilitation Program Benefit (14-0009)

Form 100B — Answer Concerning Vocational Rehabilitation Program Benefit (14-0009A)

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Alternate Care

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

Form 100C — Answer to Petition Concerning Application for Alternate Care (14-0011A)

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Vocational Training & Education Under Iowa Code Section 85.70(2)

Form 100D — Original Notice & Petition Concerning  Application for Vocational Training & Education for Shoulder Injuries (14-0012)

Form 100D — Answer to Petition Concerning Application for Vocational Training & Education for Shoulder Injuries (14-0012A)

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Hearing

Hearing Report

Hearing Report — No Second Injury Fund (14-0047)

Hearing Report — Second Injury Fund (14-0047)

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Shorthand Reporter Identification

Shorthand Reporter Identification (14-0178)

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Settlement

Agreement for Settlement (14-0021)

Compromise Settlement (14-0025)

Combination Settlement (14-0159)

Contingent Settlement (14-0161)

Claimant's Statement (14-0163)

Payment Activity Report (PAR) for Settlements (14-0147)

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Commutation

Full Commutation (14-0013)

Partial Commutation (14-0017)

Payment Activity Report (PAR) for Commutations (14-0147)

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Filing

Application to Defer Payment of Filing Fees & Financial Affidavit (14-0075)

Application for eFiling Exception (14-0176)

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Information Requests to DWC

Information Request (14-0083)

Authorization to the Iowa Division of Workers' Compensation to Release Information (14-0196)

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EDI & Compliance

First Report of Injury (FROI) (14-0001)

Payment Activity Report (PAR) for EDI & Compliance (14-0174)

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Miscellaneous

Application for Payment of Benefits (14-0037)

Medical Report Transmittal Form (14-0141)

Dispute Resolution Conference Report (14-0041)

Authorization to Release Information Regarding Claimant Seeking Workers' Compensation Benefits (14-0043)

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