Workers’ Compensation Documents

Title Link to File
Instructions for Original Notice & Petition Concerning Application for Alternate Care — Form 100C (14-0011) Instructions for Form -- Alternate Care -- Original Notice & Petition -- 2019.10.15.pdf
Instructions for Answer Concerning Independent Medical Examination — Form 100A (14-0007A) Instructions for Form -- Independent Medical Examination -- Answer -- July 2019.pdf
Instructions for Answer Concerning Application for Alternate Care, Form 100C (14-0011A) Instructions for Form -- Alternate Care -- Answer -- July 2019.pdf
How to Request a Hearing on WCES How to Schedule a Hearing -- WCES Filer Quick Start Guide -- 2019.1010.pdf
Form — Unrepresented Claimant's Statement — 14-0163 14-0163.pdf
Form — Shorthand Reporter Identification — 14-0178 Shorthand Report Identification -- Form 14-0178 -- July 2019.pdf
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