How to Complete the Workers' Compensation Decline Form in Iowa

What the Decline Form Covers in Iowa

The Iowa Workers' Compensation Decline Form (Form W-1) is used when an employer or the state denies a claim or the claimant chooses to decline the settlement offered. Unlike federal forms, Iowa requires specific details about the injury, medical treatment, and the reason for decline. The form must be signed by both the claimant and the employer's representative, and a copy is sent to the Iowa Department of Labor.

Step‑by‑Step Completion Guide

1. Gather Required Documents

• Original claim number and claimant's ID
• Medical reports and bills related to the injury
• Any prior settlement offers or correspondence

2. Fill in Personal and Claim Information

Enter the claimant's full name, address, Social Security number, and the incident date. The claim number should match the one on the Iowa Department of Labor's online portal.

3. Detail the Reason for Decline

Choose the appropriate box: "Denial by Employer," "Denial by State," or "Voluntary Decline." Provide a concise explanation, citing specific policy clauses or medical evidence if applicable.

4. Attach Supporting Evidence

Attach copies of medical records, treatment plans, and any correspondence that supports the decline. Label each attachment clearly and reference them in the form's remarks section.

5. Signatures and Dates

Both claimant and employer representative must sign and date the form. The employer representative must also provide their name, title, and company affiliation.

6. Submit the Form

Send the completed form to the Iowa Department of Labor by mail or fax. Retain a copy for the claimant's records.

Common Pitfalls to Avoid

• Missing the claimant's Social Security number—this triggers a processing delay.
• Using ambiguous language in the reason for decline—specify policy references or medical conclusions.
• Failing to attach all requested medical documentation—an incomplete file can be rejected.

What Happens After Submission?

Once received, the Department reviews the form within 30 days. If the decline is upheld, the claimant may pursue an appeal within 60 days of notice. If denied, the claimant can file a lawsuit in the Iowa Workers' Compensation Court.

Helpful Resources