Workers’ Compensation Documents

Title Link to File
Form — Settlements & Commutations — Payment Activity Report (PAR) — 14-0147 Settlements & Commutations -- Payment Activity Report (PAR) -- Form 14-0147.pdf
Form — Medical Report Transmittal — 14-0141 14-0141medtransmit.pdf
Form — Information Request — 14-0083 Information Request -- Form 14-0083 -- 2020.01.pdf
Form — Hearing Report — Second Injury Fund — 14-0047 Hearing Report -- Second Injury Fund -- Form 14-0047 - Word -- Sep. 2019.docx
Form — Hearing Report — No Second Injury Fund — 14-0047 Hearing Report -- No Second Injury Fund -- Form 14-0047 - Word -- Sep. 2019.docx
Form — EDI & Compliance — Payment Activity Report (PAR) — 14-0147 EDI & Compliance -- Payment Activity Report (PAR) -- Form 14-0147.pdf
Form — Dispute Resolution Conference Report — 14-0041 14-0041.pdf
Form — Contingent Settlement — 14-0161 Contingent Settlement -- Form 14-0161 -- July 2019.pdf
Form — Compromise Settlement — 14-0025 Compromise Settlement -- Form 14-0025 -- 2019.10.pdf
Form — Combination Settlement — 14-0159 Combination Settlement -- Form 14-0159 -- July 2019.pdf
Form — Claimant's Confidential Information Sheet — 14-0171 14-0171-CONFIDENTIAL.pdf
Form — Authorization to Release Information Regarding Claimant Seeking Workers' Compensation Benefits — 14-0043 Form -- Authorization to Release Claimant's Information -- 14-0043.pdf
Form — Authorization for the Iowa Division of Workers' Compensation to Release Information — 14-0169 Authorization to Release Information -- Form 14-0196 -- Updated July 2019 -- Iowa Division of Workers' Compensation.pdf
Form — Application to Defer Payment of Filing Fees & Financial Affidavit — 14-0075 Application to Defer Payment of Filing Fees -- Form 14-0075 -- July 2019.pdf
Form — Application for Payment of Benefits — 14-0037 Application for Payment of Benefits -- Form 14-0037 -- July 2019.pdf
Form — Application for eFiling Exception — 14-0176 Application for eFiling Exception -- Form 14-0176 -- July 2019.pdf
Form — Agreement for Settlement — 14-0021 Agreement for Settlement -- Form 14-0021 -- 2019.07 empty.pdf
Form 9A — Partial Commutation — 14-0017 Partial Commutation -- Original Notice & Petition -- Form 9A - 14-0017 --July 2019.pdf
Form 9 — Full Commutation of All Remaining Benefits of 10 Weeks or More — 14-0013 Full Commutation -- Original Notice & Petition -- Form 9 - 14-0013 -- July 2019.pdf
Form 100D — Original Notice & Petition — Vocational Training & Education for Shoulder Injuries — 14-0012 Form 100D -- Vocational Training & Education -- Original Notice & Petition --14-0012 -- Dec. 2019.pdf
Form 100D — Answer — Vocational Training & Education — 14-0012A Form 100D -- Vocational Training & Education -- Answer -- 14-0012A.pdf
Form 100C — Original Notice & Petition — Alternate Care — 14-0011 Alternate Care -- Original Notice & Petition -- Form 100C - 14-0011 -- July 2019.pdf
Form 100C — Answer — Alternate Care — 14-0011A Alternate Care -- Answer -- Form 100C - 14-0011A -- July 2019.pdf
Form 100B — Original Notice & Petition — Vocational Rehabilitation Program Benefit — 14-0009 Vocational Rehabilitation Program Benefit -- Form 100B - 14-0009 -- July 2019.pdf
Form 100B — Answer — Vocational Rehabilitation Program Benefit — 14-0009A Vocational Rehabilitation Program Benefit -- Answer -- Form 100B - 14-0009A -- July 2019.pdf