Workers’ Compensation Claim Forms - Wolters Kluwerfrg.wolterskluwerfs.com/Workers_Compensation_Claims.pdfThe Workers Compensation Claim Forms listed in ... Forms are in text provided

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Workers’ Compensation Claim Forms

Alphabetical Index

The Workers Compensation Claim Forms listed in this Reference Guide include, but are not limited to, injury reports, claim denials, petitions, treatingphysician forms, and wage statements. Also included are various claim forms which may be used during the lifecycle of a claim, claim and benefitdetermination and claim settlement.

The forms listed, which WOLTERS KLUWER makes available as stock items, are as follows:

1. General Use: Forms are in text emanating from the U.S. Department of Labor, Bureau of Employees Compensation, and Industrial Accident Boardsand Commissions.

2. Specific State Forms: Forms are in text provided by the Industrial Accident Board or other official body having jurisdiction in each state.

All forms are in compliance with prescribed specifications, (i.e. size, color and weight of stock, etc.), and are listed alphabetically by form title.

‘‘Uncontrolled’’ Forms: Uncontrolled forms (i.e. no industry source) are developed by WOLTERS KLUWER as a result of individual company demand to satisfyfederal or state regulatory requirements.

Monopolistic Jurisdictions: Unless otherwise indicated, forms listed are NOT for use in jurisdictions having a "monopolistic" Workers Compensation program.



UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE

--------------------------------------------------------GENERAL USE

--------------------------------------------------------(A)

WC8543 D 03/14 LS-266 APPLICATION FOR CONTINUATION OFDEATH BENEFIT FOR STUDENT

FD

WC7542 01/03 LS-33 APPROVAL OF COMPROMISE OF THIRDPERSON CAUSE OF ACTION

FD

WC7568 E 04/12 LS-204 ATTENDING PHYSICIAN'SSUPPLEMENTARY REPORT

FD

(C)WC8180 E 01/10 LS570 CARRIER'S REPORT OF ISSUANCE OF

POLICYFD

WC8542 D 09/10 LS-265 CERTIFICATION OF FUNERAL EXPENSES FDWC7625 E 04/12 LS-262 CLAIM FOR DEATH BENEFITS FDWC9492 B 03/12 LS-267 CLAIMANT'S STATEMENT FDWC9521 C 07/13 SSA3288 CONSENT FOR RELEASE OF

INFORMATION (SSA)FD

(E)WC8079 G 08/14 LS-203 EMPLOYEE'S CLAIM FOR

COMPENSATIONFD

WC7750 G 04/12 LS-202 EMPLOYER'S FIRST REPORT OF INJURYOR OCCUPATIONAL ILLNESS

FD

WC8083 F 03/14 LS-210 EMPLOYER'S SUPPLEMENTARY REPORTOF ACCIDENT OR OCCUPATIONALILLNESS

FD

(F)WC8899 02/95 IA10295- FIRST REPORT OF INJURY OR ILLNESS AK , AL , AR , AZ , CA , CO , CT , DC ,

DE , FL , GA , GU , HI , IA , ID , IL ,IN , KS , KY , LA , MA , MD , ME ,MI , MN , MO , MS , MT , NC , ND ,NE , NH , NJ , NM , NV , NY , OH ,

OK , OR , PR , RI , SC , SD , TN , TX ,UT , VA , VI , VT , WA , WI , WV , WY

WC9250 12/98 FORM121298 FIRST REPORT OF INJURY OR ILLNESS(IAIABC FORM 1.2 (12/98))

AK , AL , AR , AZ , CA , CO , CT , DC ,DE , FL , GA , GU , HI , IA , ID , IL ,IN , KS , KY , LA , MA , MD , ME ,MI , MN , MO , MS , MT , NC , ND ,NE , NH , NJ , NM , NV , NY , OH ,


(H)WC1578 D 02/12 CMS 1500 HEALTH INSURANCE CLAIM FORM FD

(I)WC9991 09/15 440-3923A IME OBSERVER FORM OR

(N)WC8013 J 05/15 LS-207 NOTICE OF CONTROVERSION OF RIGHT

TO COMPENSATIONFD

WC8076 E 04/09 LS201 NOTICE OF EMPLOYEE'S INJURY ORDEATH

FD

WC8189 J 01/18 LS-208 NOTICE OF FINAL PAYMENT ORSUSPENSION OF COMPENSATIONPAYMENTS

FD

(P)WC8012 H 01/15 LS-206 PAYMENT OF COMPENSATION WITHOUT

AWARDFD

WC7623 B 10/98 LS-205 PHYSICIAN'S REPORT ON IMPAIRMENTOF VISION

FD

WC8541 C 09/10 LS-18 PRE-HEARING STATEMENT FD(R)

WC7718 C 04/09 LS-200 REPORT OF EARNINGS FD




WC7560 F 11/17 LS-1 REQUEST FOR EXAMINATION AND/ORTREATMENT

FD

WC9500 C 08/14 SSA-7050-F4 REQUEST FOR SOCIAL SECURITYEARNINGS INFORMATION

FD

WC7504 D 03/12 LS-426 REQUEST TO EMPLOYEE FOR WAGEEARNINGS INFORMATION

FD

(U)WC9611 07/05 UNIT STATISTICAL PLAN - INDIVIDUAL

CLAIM REPORTAK , AL , AR , AZ , CA , CO , CT , DC ,DE , FL , GA , HI , IA , ID , IL , IN , KS ,

KY , LA , MA , MD , ME , MI , MN , MO ,MS , MT , NC , ND , NE , NH , NJ , NM ,NV , NY , OH , OR , RI , SC , SD , TN ,

TX , UT , VA , VT , WA , WI , WV , WY(W)

WC1596 D 08/14 OWCP-5B WORK CAPACITY EVALUATION(CARDIOVASCULAR/PULMONARYCONDITIONS)

FD

WC1597 D 08/14 OWCP-5C WORK CAPACITY EVALUATION(MUSCULOSKELETAL CONDITIONS)

FD

WC1593 D 08/14 OWCP-5A WORK CAPACITY EVALUATION(PSYCHIATRIC/PSYCHOLOGICALCONDITIONS)

FD

WC9992 07/16 FORM #413 WORKER’S SUPPLEMENTAL CLAIMFORM

AZ

WC9021 01/02 IA10102 WORKERS COMPENSATION - FIRSTREPORT OF INJURY OR ILLNESS

AR , KY , LA , NJ

WC8552 01/99 IA-2 WORKERS COMPENSATION -SUBSEQUENT REPORT

KY

WC8900 01/99 IA20199 WORKERS COMPENSATION -SUBSEQUENT REPORT

AK , AL , AR , AZ , CA , CO , CT , DC ,DE , FL , GA , GU , HI , IA , ID , IL ,IN , KS , KY , LA , MA , MD , ME ,MI , MN , MO , MS , MT , NC , ND ,NE , NH , NJ , NM , NV , NY , OH ,


--------------------------------------------------------STATE SPECIFIC

--------------------------------------------------------Alabama

WC8078 B 10/12 WC 4 CLAIM SUMMARY FORMWC9119 B 10/12 COMBINATION SUPPLEMENTARY &

CLAIM SUMMARY FORMWC8071 K 10/12 WCC FORM 2 EMPLOYER'S FIRST REPORT OF INJURY

OR OCCUPATIONAL DISEASEWC1524 C 10/12 WC FORM 3 SUPPLEMENTARY REPORTWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

AlaskaWC8790 A 02/10 07-6175 AFFIDAVIT OF COMPENSATION RATE

LESS THAN $154WC9326 D 04/11 FORM 07-6107 AFFIDAVIT OF READINESS FOR HEARINGWC8441 K 12/15 FORM 07-6104B COMPENSATION REPORT - THIS FORM IS

AVAILABLE IN EFORM ONLY.WC8789 A 04/10 07-6117 COMPROMISE & RELEASE AGREEMENT

SUMMARYWC8436 H 11/14 FORM 07-6105 CONTROVERSION NOTICE - THIS FORM

IS AVAILABLE IN EFORM ONLY.WC8437 B 04/10 07-6118 DEATH BENEFITS REPORTWC9925 A 04/15 07-6100 EMPLOYEE REPORT OF OCCUPATIONAL

INJURY OR ILLNESS TO EMPLOYERWC9433 R 03/18 07-6101




EMPLOYER REPORT OF OCCUPATIONALINJURY OR ILLNESS - THIS FORM ISAVAILABLE IN EFORM ONLY.

WC9738 B 05/12 07-6103 MEDICAL SUMMARYWC9962 09/12 FORM 07-6110 NOTICE OF POSSIBLE CLAIM AGAINST

THE SECOND INJURY FUNDWC9327 D 07/16 07-6111 PETITION (DO NOT USE AS A CLAIM FOR

BENEFITS)WC9327 E 09/17 07-6111 PETITION (DO NOT USE AS A CLAIM FOR

BENEFITS)WC9809 B 02/15 07-6170 REEMPLOYMENT EMPLOYER NOTICE OF

45 CONSECUTIVE DAYS OF TIME LOSSFOR INJURIES

WC9808 B 02/15 07-6169 REEMPLOYMENT EMPLOYER NOTICE OF90 CONSECUTIVE DAYS OF TIME LOSSFOR INJURIES

WC9807 B 02/15 07-6152 REEMPLOYMENT STIPULATION TOELIGIBILITY FOR INJURIES

WC9727 06/03 RELEASE OF COUNSELING,PSYCHOLOGICAL, PSYCHIATRIC,OR ALCOHOL/DRUG/SUBSTANCEABUSE TREATMENT RECORDS ORINFORMATION

WC9583 B 05/11 07-6146 RELEASE OF MEDICAL INFORMATIONWC9328 B 11/11 07-6135 REQUEST FOR CONFERENCEWC9329 01/94 FORM0761740194 REQUEST FOR CROSS-EXAMINATIONWC9753 J 10/16 07-6121 REQUEST FOR RELEASE OF

INFORMATIONWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC8788 E 12/17 07-6106 WORKERS' COMPENSATION CLAIM

ArizonaWC9434 A 05/17 ICA 0120 CLAIM FOR DEPENDENT'S BENEFITS —

FATALITYWC8418 E 07/01 ICA0401010701 EMPLOYER'S REPORT OF INDUSTRIAL

INJURYWC8420 J 01/16 FORM 104 NOTICE OF CLAIM STATUSWC8404 B 06/15 110-B NOTICE OF INTENT TO SUSPENDWC8405 A 03/95 ICA0411184REV94 NOTICE OF PERMANENT

COMPENSATION PAYMENT PLANWC8402 A 01/94 ICA0410786 NOTICE OF PERMANENT DISABILITY

AND REQUEST FOR DETERMINATION OFBENEFITS

WC8401 A 03/95 ICA04010680 NOTICE OF PERMANENT DISABILITY ORDEATH BENEFITS

WC1525 E 07/00 ICA-04010380 NOTICE OF SUPPORTIVE MEDICALMAINTENANCE BENEFITS

WC8400 B 06/98 ICAD40105800698 NOTICE OF SUSPENSION OF BENEFITSWC8722 A 06/00 ICA040529710600 PETITION FOR REARRANGEMENT OR

READJUSTMENT OF COMPENSATIONWC8845 B 05/17 ICA 0528 PETITION TO REOPEN BASED ON

NEW, ADDITIONAL OR PREVIOUSLYUNDISCOVERED DISABILITY ORCONDITION

WC9981 A 10/16 MRO-1 PRE-AUTHORIZATION REQUEST ANDPAYER DECISION

WC8419 E 06/94 ICA04010875 RECOMMENDED AVERAGE MONTHLYWAGE CALCULATION OF CARRIER

WC9008 C 07/11 REPORT OF SIGNIFICANT WORKEXPOSURE TO BODILY FLUIDS

WC8721 C 05/02 ICA 0446 REQUEST FOR HEARINGWC9436 D 07/13 REQUEST TO CHANGE DOCTORS




WC9437 D 07/13 REQUEST TO LEAVE STATEWC9330 06/03 WAIVER OF RIGHT OF REHEARING AND

APPEALSWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC8403 B 06/15 110-A WORKERS' ANNUAL REPORT OF INCOMEWC8813 C 05/17 ICA 0407 WORKER'S REPORT OF INJURY

ArkansasWC9728 01/07 AUTHORIZATION FOR RELEASE OF

MEDICAL RECORDSWC7892 E 06/14 AR-C CLAIM FOR COMPENSATIONWC7917 B 01/01 FORMARL0101 CLAIMANT'S LUMP SUM REQUEST/

RESPONDENT'S POSITIONWC7902 B 01/01 FORMARD0101 DEATH AND PERMANENT TOTAL

DISABILITY ACCEPTANCE/UPDATEWC7929 E 08/06 FORMARN0806 EMPLOYEE'S NOTICE OF INJURYWC9570 A 08/06 FORMARN0806 EMPLOYEE'S NOTICE OF INJURY

(SPANISH)WC7880 E 01/13 AR-2 EMPLOYER'S INTENT TO ACCEPT OR

CONTROVERT CLAIMWC8368 C 01/02 FORM 1 FIRST REPORT OF INJURY OR ILLNESSWC7918 B 01/01 FORMARM0101 MONTHLY REPORT ON MEDICAL-ONLY

INJURY DATAWC7887 B 01/01 FORMAR30101 PHYSICIAN'S REPORTWC7889 D 01/11 FORM AR-4 REPORT OF COMPENSATION PAID/

SUSPENSION OF PAYMENTSWC7906 B 01/01 FORMARS0101 SUPPLEMENTAL REPORTWC7798 A 01/01 FORM AR-V VERIFICATION OF PERMANENT TOTAL

DISABILITYWC7962 B 01/01 FORMARW0101 WAGE STATEMENT IMMEDIATELY

PRECEDING INJURY DATEWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

CaliforniaWC9816 A 10/13 QME FORM 31.7 ADDITIONAL PANEL REQUESTWC9198 11/02 WCAB001 ADDRESS RECORD CHANGEWC8767 09/99 WCAB003 AFFIDAVIT OF DEFENDANT RE:

RESOLUTION OF LIENSWCAB10 11/08 DWC/WCAB FORM 10 ANSWER TO APP FOR ADJ OF CLAIM

(AVAILABLE ELECTRONICALLY IN PDFFILL ONLY)

WC9912 A 03/13 FACT SHEET C ANSWERS TO YOUR QUESTIONS ABOURTEMPORARY DISABILITY BENEFITS

WC9919 03/13 FACT SHEET C (SPANISH) ANSWERS TO YOUR QUESTIONS ABOURTEMPORARY DISABILITY BENEFITS(SPANISH)

WC9916 03/13 FACT SHEET D(SPANISH) ANSWERS TO YOUR QUESTIONS ABOUTPERMANENT DISABILITY BENEFITS

WC9908 A 03/13 FACT SHEET D ANSWERS TO YOUR QUESTIONS ABOUTPERMANENT DISABILITY BENEFITS

WC9913 A 03/13 FACT SHEET E ANSWERS TO YOUR QUESTIONS ABOUTQUALIFIED MEDICAL EVALUATORS ANDAGREED MEDICAL EVALUATORS

WC9920 A 06/14 FACT SHEET E (SPANISH) ANSWERS TO YOUR QUESTIONS ABOUTQUALIFIED MEDICAL EVALUATORSAND AGREED MEDICAL EVALUATORS(SPANISH)

WC9914 A 03/13 FACT SHEET F ANSWERS TO YOUR QUESTIONS ABOUTTHE STATE'S UNINSURED EMPLOYER'SBENEFITS TRUST FUND

WC9921 03/13 FACT SHEET F (SPANISH) ANSWERS TO YOUR QUESTIONS ABOUTTHE STATE'S UNINSURED EMPLOYER'SBENEFITS TRUST FUND (SPANISH)




WC9910 B 03/14 FACT SHEET A (ENGLISH) ANSWERS TO YOUR QUESTIONS ABOUTUTILIZATION REVIEW

WC9917 A 03/14 FACT SHEET A (SPANISH) ANSWERS TO YOUR QUESTIONS ABOUTUTILIZATION REVIEW (SPANISH)

WCAB1A 11/08 DWC/WCAB FORM 1A APP FOR ADJUDICATION OF CLAIM(AVAILABLE ELECTRONICALLY IN PDFFILL ONLY)

WC9199 07/81 DIA20781 APPLICATION FOR ADJUDICATION OFCLAIM (DEATH CASE)

WC8996 D 09/15 QME 100 APPLICATION FOR APPOINTMENT ASQUALIFIED MEDICAL EVALUATOR

WC9900 A 02/14 DWC FORM IMR APPLICATION FOR INDEPENDENTMEDICAL REVIEW

CASIFAPP 11/08 APPSIF APPLICATION FOR SIF BENEFITS(AVAILABLE ELECTRONICALLY IN PDFFILL ONLY)

DWC10297 11/08 DWC CA FORM 10297 ARBITRATION SUBMITTAL FORM(AVAILABLE ELECTRONICALLY IN PDFFILL ONLY)

WC9206 11/02 ATTACHMENT PAGEWC9909 07/10 FACT SHEET IW BASIC FACTS ON WORKERS'

COMPENSATION FOR INJUREDWORKERS

WC9915 05/10 FACT SHEET IW SP BASIC FACTS ON WORKERS'COMPENSATION FOR INJUREDWORKERS (SPANISH)

WC6916 A 01/03 DWC11940103 CHOOSING MEDICAL CARE FOR WORK-RELATED INJURIES AND ILLNESS

DWC10214C 11/08 DWC FORM 10214 C COMPROMISE AND RELEASE(AVAILABLE ELECTRONICALLY IN PDFFILL ONLY)

DWC10214D 11/08 DWC FORM 10214 D COMPROMISE-RELEASE DEPEND CLAIM(AVAILABLE ELECTRONICALLY IN PDFFILL ONLY)

DWC10214E 11/08 DWC FORM 10214 E COMPROMISE-RELEASE DEPEND CLAIM(AVAILABLE ELECTRONICALLY IN PDFFILL ONLY)

WC9499 F 08/17 FORM 807 COVERAGE RESEARCH SERVICEREQUEST

DWC102521 11/08 DWC CA FORM 10252 1 DECL OF READINESS - EXPEDITED TRIAL(AVAILABLE ELECTRONICALLY IN PDFFILL ONLY)

WC9201 11/02 LS600 DECLARATION OF CUSTODIAN OFRECORDS

DWC102501 06/11 DWC-CA FORM 10250.1 DECLARATION OF READINESSTO PROCEED (AVAILABLEELECTRONICALLY IN PDF FILL ONLY)

DWC10208 04/14 DWC-CA 10208.3 DECLARATION OF READINESSTO PROCEED (EXPEDITED TRIAL)(AVAILABLE ELECTRONICALLY IN PDFFILL ONLY)

WC6921 05/02 WC004 DECLARATION PURSUANT TO LABORCODE SECTION 4906(G)

WC9897 A 01/14 DWCAD 10133.33 DESCRIPTION OF EMPLOYEE'S JOBDUTIES

WC9261 04/03 DILIGENT SEARCH REPORTWC9318 11/78 DIA4001178 DISABILITY EVALUATION BUREAUWC9202 11/02 DWC2 DISCLOSURE STATEMENT

WITHDRAWALWC8358 F 10/15 FORM 5021 DOCTOR'S FIRST REPORT OF

OCCUPATIONAL INJURY OR ILLNESS




DWC102321 09/14 DWC-CA FORM 10232.1 DOCUMENT COVER SHEET (AVAILABLEELECTRONICALLY IN PDF FILL ONLY)

DWC102322 09/14 DWC-CA FORM 10232.2 DOCUMENT SEPARATOR SHEET(AVAILABLE ELECTRONICALLY IN PDFFILL ONLY)

WC8359 K 10/02 5020REV70602 EMPLOYER'S FIRST REPORT OFOCCUPATIONAL INJURY OR ILLNESS

DWCAD100 11/08 DWCAD FORM 100 DEU EMPLY PERM DISABILITYQUESTIONNAIRE (AVAILABLEELECTRONICALLY IN PDF FILL ONLY)

WC9286 06/03 WCAB106 EXHIBIT AND WITNESS COVER SHEETWC6925 B 01/17 DWC 3 FEE DISCLOSURE STATEMENTWC9911 A 03/13 FACT SHEET B GLOSSARY OF WORKERS'

COMPENSATION TERMS FOR INJUREDWORKERS

WC9918 03/13 FACT SHEET B (SPANISH) GLOSSARY OF WORKERS'COMPENSATION TERMS FOR INJUREDWORKERS (SPANISH)

WC9235 01/03 HELP IN RETURNING TO WORK(PAMPHLET)

WC9947 11/14 I&A 1 HOW TO FILE A WORKERS'COMPENSATION CLAIM FORM

WC9590 B 05/07 WC9590B 05/07 INDEPENDENT MEDICAL REVIEWAPPLICATION

WC9627 Q 12/17 I&A MILEAGE FORM MEDICAL MILEAGE EXPENSE FORM (FORMILEAGE AFTER 7/1/2011)

DWC10245 11/08 DWC 10245 MINUTES OF HEARING (AVAILABLEELECTRONICALLY IN PDF FILL ONLY)

WC8761 08/90 WCABFORM370890 NOTICE OF DISMISSAL OF ATTORNEYWC8473 09/84 DIA5100984 NOTICE OF EMPLOYEE DEATHWC9289 06/03 WC001 NOTICE OF HEARING TO LIEN

CLAIMANTSWC9893 A 01/14 DWCAD 10133.53 NOTICE OF OFFER OF MODIFIED OR

ALTERNATIVE WORK (INJURIES FROM1/1/04 TO 12/31/12)

WC9892 A 01/14 DWCAD 10118 NOTICE OF OFFER OF REGULAR WORK(INJURIES FROM 1/1/05 TO 12/31/12)

WC9894 A 01/14 DWCAD 10133.35 NOTICE OF OFFER OF REGULAR,MODIFIED, OR ALTERNATIVE WORK(INJURIES ON OR AFTER 1/1/13)

WC9683 A 07/14 DWC FORM 9783.1 NOTICE OF PERSONAL CHIROPRACTOROR PERSONAL ACUPUNTURIST

WC9210 11/02 WC18 NOTICE OF TAKING DEPOSITIONWCAB6 11/08 DWC WCAB FORM 6 NOTICE OF TERM OF VOC

REHAB SERVICES (AVAILABLEELECTRONICALLY IN PDF FILL ONLY)

WC1516 C 05/07 DWC FORM 233 OBJECTION TO TREATING PHYSICIAN'SRECOMMENDATION FOR SPINALSURGERY

WC9294 06/03 WC1050 ORDER AND DECISION ON REQUEST FORCONTINUANCE OR OFF CALENDAR

WC9299 05/75 DIA650575 ORDER APPROVING COMPROMISE ANDRELEASE

WC9295 06/03 DIA65F ORDER APPROVING COMPROMISE ANDRELEASE

WC9296 06/03 LS65 ORDER APPROVING COMPROMISE ANDRELEASE

WC9298 06/03 DIA65D ORDER APPROVING COMPROMISE ANDRELEASE

WC9300 06/03 DIA65E ORDER APPROVING COMPROMISE ANDRELEASE




WC9303 06/03 DIA65B ORDER APPROVING COMPROMISE ANDRELEASE

WC9297 06/03 DIA65P ORDER APPROVING COMPROMISE ANDRELEASE

WC9302 06/03 DIA65A ORDER APPROVING COMPROMISE ANDRELEASE

WC9551 07/04 ORDER APPROVING COMPROMISE ANDRELEASE

WC9195 10/02 DIA65C ORDER APPROVING COMPROMISE ANDRELEASE (RELEASE OF APPLICANT'SDEPENDENTS' RIGHTS TO DEATH)

WC9301 06/03 WCAB5 ORDER APPROVING COMPROMISEAND RELEASE (THE RIGHT TOREHABILITATION IS NOT ABROGATEDBY THIS ORDER)

WC9214 10/74 WCAB671074 ORDER APPROVING COMPROMISE ANDRELEASE (THIRD PARTY SETTLEMENT)

WC9304 03/90 WCAB520390 ORDER DISMISSING PARTY DEFENDANTWC9305 06/03 WC905 ORDER GRANTING PAYMENT OF LIEN

CLAIMWC9306 02/75 WCAB530275 ORDER JOINING PARTY DEFENDANTWC9307 12/75 WCAB511275 ORDER OF DISMISSALWC9213 08/75 WCAB590875 ORDER TO REPORT TO INDEPENDENT

MEDICAL EXAMINERWCAB46 11/08 DWC/WCAB FORM 46 PET TO DETERMINE LIABILITY FOR

TEMP (AVAILABLE ELECTRONICALLY INPDF FILL ONLY)

WC9308 06/03 WC100 PETITION FORWC9215 10/90 WCAB81090 PETITION FOR APPOINTMENT OF

GUARDIAN AD ITEM AND TRUSTEEWC9309 A 01/01 DWC2800101 PETITION FOR CHANGE OF PRIMARY

TREATING PHYSICIANWC9020 11/74 DWCWCAB491174 PETITION FOR COMMUTATION OF

FUTURE PAYMENTSWC9310 06/03 WC900 PETITION FOR ORDER ALLOWING

ATTORNEY'S FEESWC9277 02/91 WCAB310291 PETITION FOR ORDER ALLOWING PRE-

APPLICATION ATTORNEY FEE ANDORDER

WC9311 11/76 WCAB411176 PETITION FOR PERMANENT DISABILITYRATING

WC9278 02/91 WCAB300291 PETITION FOR PRE-APPLICATIONDISCOVERY ORDER

WC9019 A 04/14 DWC/WCAB FORM 45 PETITION FOR RECONSIDERATIONWC9312 08/85 WCAB420885 PETITION TO REOPENWC9898 A 01/14 DWCAD 10133.36 PHYSICIAN'S RETURN-TO-WORK &

VOUCHER REPORTWC9682 B 07/14 DWC FORM 9783 PREDESIGNATION OF PERSONAL

PHYSICIANWC9314 A 09/10 DWC FORM 10253.1 PRE-TRIAL CONFERENCE STATEMENT

§5502 (D) (3)WC9589 C 02/16 PR-4 PRIMARY TREATING PHYSICIAN'S

PERMANENT AND STATIONARY REPORTWC9238 D 10/15 PR-3 PRIMARY TREATING PHYSICIAN'S

PERMANENT AND STATIONARY REPORTWC9239 D 10/15 PR-2 PRIMARY TREATING PHYSICIAN'S

PROGRESS REPORTWC9280 A 11/11 PROOF OF SERVICE BY MAILWC8718 C 10/13 QME FORM 110 QME APPOINTMENT NOTIFICATION

FORMWC9770 02/09 QME FORM 107 QME PANEL SELECTION




WC9769 02/09 QME FORM 108 QME PANEL SELECTION INSTRUCTIONFORM

WC8997 C 10/13 QME FORM 112 QME/AME TIME FRAME EXTENSIONREQUEST (FOR LATE REPORTING ONACCEPTED CLAIMS)

WC9260 02/09 QME FORM 111 QUALIFIED MEDICAL EVALUATOR'SFINDINGS SUMMARY FORM

WC9815 10/13 QME FORM 31.5 REPLACEMENT PANEL REQUESTDWCAD103 11/08 DWC AD FORM 103(DEU) REQ FOR RECONS OF SUMMARY RATING


DWCAD101 11/08 DWCAD FORM 101 DEU REQ FOR SUMMARY RATING BY QME(AVAILABLE ELECTRONICALLY IN PDFFILL ONLY)

DWCAD104 11/08 DWC AD FORM 104 DEU REQUEST FOR CONSULTATIVE RATING(AVAILABLE ELECTRONICALLY IN PDFFILL ONLY)

WC9316 03/90 WCAB430390 REQUEST FOR DISMISSALWC9317 03/90 WCAB43A0390 REQUEST FOR DISMISSALWC9899 A 01/14 DWCAD 10133.55 REQUEST FOR DISPUTE RESOLUTION

BEFORE ADMINISTRATIVE DIRECTORWC8677 08/90 DEU2010890 REQUEST FOR INFORMATION RATING

BY INSURANCE CARRIER OR SELF-INSURER

WC9425 E 09/15 QME 105 REQUEST FOR QME PANEL(UNREPRESENTED)

WC9792 B 09/15 QME-105 REQUEST FOR QME PANEL UNDERLABOR CODE SECTION 4062.1 –UNREPRESENTED.

WC8705 E 09/15 QME 106 REQUEST FOR QUALIFIED MEDICALEVALUATOR

DWCAD10120 11/08 DWC AD FORM10120(SJDB)

REQUEST FOR REIMBURSEMENT

DWCAD102 11/08 DWC AD FORM 102 DEU REQUEST FOR SUM RATING DET BY PTP(AVAILABLE ELECTRONICALLY IN PDFFILL ONLY)

WC6922 12/95 DWC FORM AD-1 REQUEST TO VIEW A WCAB CASE FILEWC6923 01/96 DWCFORMAD20196 REQUEST TO VIEW WCAB FILEWC9315 A 01/11 SPECIAL NOTICE OF LAWSUITWC9319 06/03 WC903 STIPULATION AND ORDER GRANTING

PAYMENT OF LIEN CLAIMDWC10214A 11/08 DWC FORM 10214(A) STIPULATION/REQUEST FOR AWARD


DWC10214A1 04/14 DWC-CA 10214 A.1 STIPULATIONS WITH REQUESTFOR AWARD (DATES OF INJURYON OR AFTER 1-1-13)(AVAILABLEELECTRONICALLY IN PDF FILL ONLY)

DWC10214B 11/08 DWC FORM 10214(B) STIPULATIONS WITH REQUEST FORAWARD (DEATH CASE)(AVAILABLEELECTRONICALLY IN PDF FILL ONLY)

WC9321 06/94 DIA300694 SUBPOENAWC9283 06/94 WCAB320694 SUBPOENA DUCES TECUMWC9279 A 01/99 WCAB36 SUBSTITUTION OF ATTORNEYSWC9895 A 01/14 DWCAD 10133.57 SUPPLEMENTAL JOB DISPLACEMENT

NONTRANSFERABLE TRAININGVOUCHER (INJURIES FROM 1/1/04 TO12/31/12)

WC9593 01/05 SUPPLEMENTAL LOSS REPORTWC9323 06/03 WC65 SUPPLEMENTAL ORDER APPROVING

COMPROMISE AND RELEASE




WC9236 F 07/14 TIME OF HIRE PAMPHLETWC9271 F 07/14 TIME OF HIRE PAMPHLET (SPANISH)WC9592 01/05 UNIT STATISTICAL REPORTWC9721 A 04/14 DWC UR UTILIZATION REVIEW (UR) COMPLAINT

FORMWC9324 06/03 WC105 VENUE AUTHORIZATIONWC9325 06/03 WC007 VENUE AUTHORIZATIONWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC8222 E 01/16 DWC1 WORKERS' COMPENSATION CLAIM

FORM (DWC 1) & NOTICE OF POTENTIALELIGIBILITY

ColoradoWC8623 F 05/05 WC770505 APPLICATION FOR A DIVISION

INDEPENDENT MEDICAL EXAMINATION(IME)

WC9100 F 11/13 APPLICATION FOR HEARING ANDNOTICE TO SET

WC9156 C 01/06 WC350106 APPLICATION FOR INDIGENTDETERMINATION

WC9157 G 08/15 WC035(IME) APPLICATION FOR INDIGENTDETERMINATION (IME)

WC8909 C 05/06 DK10506 AVERAGE WEEKLY WAGE WORKSHEETWC8524 D 04/06 WC180406 DEPENDENTS' NOTICE AND CLAIM FOR

COMPENSATIONWC8492 E 03/14 WC105 DIVISION OF WORKERS' COMPENSATION

SETTLEMENT CHECKLIST AND ROUTINGSHEET

WC8062 R 01/06 WC10106 EMPLOYER'S FIRST REPORT OF INJURYWC9155 D 03/15 ENTRY OF APPEARANCEWC8625 E 06/05 WC1530605 FATAL CASE - FINAL ADMISSIONWC8624 B 05/05 WC1510505 FATAL CASE - GENERAL ADMISSIONWC8244 T 07/14 WC4 FINAL ADMISSION OF LIABILITYWC8814 B 05/05 WC1060505 FIRST REPORT TRANSMITTALWC8242 M 07/14 WC2 GENERAL ADMISSION OF LIABILITYWC9159 G 06/16 WC132 IME EXAMINER'S SUMMARY SHEETWC9789 A 04/10 WC 036 INFORMATION REGARDING

INDEPENDENT MEDICAL EXAMINATIONWC9821 06/10 INFORMATION REGARDING WORKERS'

COMPENSATION AND A CLAIMANT'SRIGHTS

WC8911 B 01/06 WCO980106 MONTHLY SUMMARYWC9940 03/15 WC192 MOTION TO CLOSE CLAIM FOR FAILURE

TO PROSECUTEWC8622 H 07/10 WC146 NOTICE AND PROPOSAL TO SELECT AN

INDEPENDENT MEDICAL EXAMINERWC9160 B 01/06 WC1680106 NOTICE OF CHANGE OF CARRIER OR

ADJUSTING FIRMWC8007 F 04/08 WC-74 NOTICE OF CONTESTWC8862 A 05/05 WC1650505 NOTICE OF FAILED IME NEGOTIATIONWC9785 B 06/15 WC003 NOTICE OF ONE-TIME CHANGE OF

PHYSICIAN & AUTHORIZATION FORRELEASE OF MEDICAL INFORMATION

WC9438 C 12/17 WC-M3-PSYCH PERMANENT WORK-RELATED MENTALIMPAIRMENT RATING REPORTWORKSHEET

WC8250 F 01/13 WC54 PETITION TO MODIFY, TERMINATE, ORSUSPEND COMPENSATION

WC8183 D 01/06 WC370106 PETITION TO REOPENWC9163 D 04/15 PETITION TO REVIEW AND REQUEST

FOR TRANSCRIPTWC8527 C 01/06 WCM40106 PHARMACY BILLING STATEMENT




WC9009 D 11/14 WC1641114 PHYSICIAN'S REPORT OF WORKER'SCOMPENSATION INJURY

WC9332 B 04/15 WC193 REQUEST FOR A DISFIGUREMENTAWARD

WC9333 C 06/16 REQUEST FOR EXPEDITED HEARINGWC8525 K 07/14 WC62 REQUEST FOR LUMP SUM PAYMENT

(PERMANENT PARTIAL, PERMANENTTOTAL AND DEPENDENTS' BENEFITS)

WC8252 E 01/06 WC630106 REQUEST FOR OFFSET OF LIABILITY TOSUBSEQUENT INJURY FUND

WC8912 C 05/16 WC1310516 REQUEST FOR UTILIZATION REVIEWWC9657 01/06 WC1780106 REQUEST/NOTIFICATION FOR FOLLOW-

UP IMEWC9162 G 03/15 RESPONSE TO APPLICATION FOR

HEARINGWC8490 B 02/09 WC 73 SETTLEMENT ORDERWC8063 H 11/17 WC12 SUPPLEMENTAL REPORT OF RETURN TO

WORKWC9439 03/01 DK70301 TEMPORARY PARTIAL DISABILITY (TPD)

BENEFIT WORKSHEETWC9942 03/14 WC191 VOLUNTARY ABANDONMENT OF CLAIMWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC8523 D 04/06 WC150406 WORKER'S CLAIM FOR COMPENSATIONWC9161 B 01/17 WC174 WORKER'S CLAIM FORM

COMPENSATION TRANSMITTALConnecticut

WC9524 C 11/09 AUTHORIZATION FOR RELEASE OFMEDICAL RECORDS BY A HOSPITAL/PROVIDER FOR THE PURPOSE OFADMINISTERING A CONNECTICUTWORKERS' COMPENSATION CLAIM FORBENEFITS

WC9822 A 09/11 EMPLOYEE MEDICAL & WORK STATUSFORM

WC7996 G 07/09 FRI EMPLOYER'S FIRST REPORT OFOCCUPATIONAL INJURY OR ILLNESS

WC7999 J 07/09 1A FILING STATUS AND EXEMPTIONWC8121 G 07/09 HR HEARING REQUESTWC9865 03/06 MILEAGE WORKSHEET FOR MEDICAL

TREATMENT - EXAMINATION -PHYSICAL THERAPY - LABORATORYTEST

WC8832 H 01/18 30C NOTICE OF CLAIM FOR COMPENSATIONWC8003 R 07/09 36 NOTICE OF INTENTION TO REDUCE OR

DISCONTINUE PAYMENTSWC7968 P 07/09 43 NOTICE TO COMPENSATION

COMMISSIONER AND EMPLOYEE OFINTENTION TO CONTEST EMPLOYEE'SRIGHT TO COMPENSATION BENEFITS

WC9120 B 03/06 NOA0306 NOTIFICATION OF APPEARANCEWC8105 D 07/09 44 ORDER TO SECOND INJURY FUND IN

CASES OF CONCURRENT EMPLOYMENTWC8833 B 03/06 PFR0306 PETITION FOR REVIEWWC7998 N 09/10 42 PHYSICIAN'S PERMANENT IMPAIRMENT

EVALUATIONWC9866 07/05 RECORD OF EMPLOYMENT CONTACTSWC9121 F 07/09 WCR-1 REHABILITATION REQUESTWC8688 E 05/14 VA VOLUNTARY AGREEMENTWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

(New) WC1015 07/16 WORKERS' COMPENSATIONINFORMATION PACKET (SPANISH)




DelawareWC9350 05/92 AFFIDAVIT REGARDING ATTORNEY'S

FEESWC7981 B 06/13 60-07-01-01 AGREEMENT AS TO COMPENSATIONWC1505 B 02/08 Form 18 AGREEMENT FOR COMPENSATION FOR

DEATHWC9772 E 10/13 EMPLOYER'S MODIFIED DUTY

AVAILABILITY REPORTWC8388 K 12/11 600702111201 FIRST REPORT OF OCCUPATIONAL

INJURY OR DISEASEWC8205 D 06/08 NOTICE OF ELECTION TO ACCEPT OR

REJECT AN INSURANCE DEDUCTIBLEFOR DELAWARE WORKERS’COMPENSATION DEATH AND MEDICALBENEFITS

WC9348 A 12/11 E60-07-12-12-11 PETITION FOR COMMUTATIONWC7980 B 12/11 F60-07-12-12-11 PETITION FOR REVIEWWC9877 12/11 G60-07-12-12-11 PETITION TO APPEAL A UTILIZATION

REVIEW (UR) DETERMINATIONWC9347 B 12/11 D60-07-12-12-11 PETITION TO DETERMINE ADDITIONAL

COMPENSATION DUE TO INJUREDEMPLOYEE

WC9313 B 05/12 A60-07 PETITION TO DETERMINECOMPENSATION DUE TO INJUREDEMPLOYEE

WC9349 A 12/11 C60-07-12-12-11 PETITION TO DETERMINEDISFIGUREMENT

WC9863 03/11 PHYS REPORT OF WC INJURY - DEWC8074 A 12/97 DOC600701021297 RECEIPT FOR COMPENSATION PAIDWC9787 C 07/15 REQUEST FOR UTILIZATION REVIEWWC8687 01/93 C060193 TERMINATION OF TEMPORARY TOTAL

DISABILITY BENEFITSWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

District of ColumbiaWC7941 A 02/14 OWN 7A EMPLOYEE'S CLAIM APPLICATIONWC8090 D 02/14 OWC 7 EMPLOYEE'S NOTICE OF ACCIDENTAL

INJURY OR OCCUPATIONAL DISEASEWC9452 06/03 EMPLOYEE'S RIGHTS AND OBLIGATIONSWC7944 C 02/14 OWC 8 EMPLOYER'S FIRST REPORT OF INJURY

OR OCCUPATIONAL DISEASEWC7970 A 02/14 OWC 12 MEDICAL REPORTWC7976 FORM 14 DCWC MEMO OF PARTIAL DISABILITYWC7950 A 02/14 OWC 9 MEMO OF PAYMENT OF WORKERS'

COMPENSATIONWC7969 A 02/14 OWC 11 NOTICE OF CONTROVERSION MEMO OF

DENIAL OF WORKERS' COMPENSATIONBENEFITS

WC7997 A 02/14 OWC 15 NOTICE OF FINAL PAYMENT OFCOMPENSATION PAYMENTS

WC7975 07/99 FORM 13 DCWC REPORT OF EXTENDED DISABILITYWC7951 A 02/14 OWC 10 WAGE SCHEDULEWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

FederalWC9888 02/10 CA-278 CLAIM FOR REIMBURSEMENT OF

BENEFIT PAYMENTS AND CLAIMSEXPENSE UNDER THE WAR HAZARDSCOMPENSATION ACT

WC8856 12/90 HCFA15001290 HEALTH INS CLM FORM HCFA-1500WC9943 03/15 LS-801 WAIVER OF SERVICE BY REGISTERED

OR CERTIFIED MAIL FOR EMPLOYERSAND/OR INSURANCE CARRIERS




FloridaWC7933 B2 03/09 DFS-F2-DWC-49 AGGREGATE CLAIMS ADMINISTRATION

CHANGE REPORTWC7963 E 03/09 DFS-F2-DWC-30 AUTHORIZATION AND REQUEST FOR

UNEMPLOYMENT COMPENSATIONINFORMATION FOR WORKFORCEINNOVATION

WC9707 A 11/06 DFS FORM 3160-0024 CARRIER RESPONSE TO PETITION FORRESOLUTION OF REIMBURSEMENTDISPUTE

WC7700 C2 03/09 DFS-F2-DWC-13 CLAIM COST REPORTWC9775 C 12/15 DFS-F3-DWC-24 DEPARTMENT AND STUDENT

AGREEMENT FOR SPONSORSHIP OFTRAINING AND EDUCATION

WC7696 B 03/09 DFS-F2-DWC-19 EMPLOYEE EARNINGS REPORTWC9504 E 07/17 EMPLOYEE NOTIFICATION LETTER

(ENGLISH)WC9505 E 07/17 EMPLOYEE NOTIFICATION LETTER

(SPANISH)WC9451 B 01/08 SDF-6 EXPLANATION OF BENEFITSWC7671 D 10/16 DFS-F2-DWC-1 FIRST REPORT OF INJURY OR ILLNESSWC8906 D 03/10 DFS-F2-DWC-65 IMPORTANT WORKERS' COMPENSATION

INFORMATION FOR FLORIDA'SEMPLOYERS

WC9722 A 03/10 DFS-F2-DWC-66 IMPORTANT WORKERS' COMPENSATIONINFORMATION FOR FLORIDA'SEMPLOYERS (SPANISH)

WC8905 E 03/10 DFS-F2-DWC-60 IMPORTANT WORKERS' COMPENSATIONINFORMATION FOR FLORIDA'SWORKERS (ENGLISH)

WC9102 F 02/14 DFS-F2-DWC-61 IMPORTANT WORKERS' COMPENSATIONINFORMATION FOR FLORIDA'SWORKERS (SPANISH)

WC7550 D2 03/09 DFS-F2-DWC-4 NOTICE OF ACTION/CHANGEWC7697 C2 03/09 DFS-F2-DWC-12 NOTICE OF DENIALWC7898 B2 03/09 DFS-F2-DWC-33 PERMANENT TOTAL OFF-SET

WORKSHEETWC7895 B2 03/09 DFS-F2-DWC-35 PERMANENT TOTAL SUPPLEMENTAL

WORKSHEETWC9017 B 04/11 PFB PETITION FOR BENEFITSWC9706 A 11/06 DFS FORM 3160-0023 PETITION FOR RESOLUTION OF

REIMBURSEMENT DISPUTEWC9847 01/08 DFS-F1-PW-2 PREFERRED WORKER REIMBURSEMENT

REQUESTWC9450 C 03/09 SDF-1 PROOF OF CLAIMWC9532 B 03/09 SDF-2 REIMBURSEMENT REQUESTWC9848 06/94 EAO-1 REQUEST FOR ASSISTANCEWC8228 C 12/15 DFS-F3-DWC-23 REQUEST FOR SCREENINGWC7594 B 03/09 DFS-F2-DWC-14 REQUEST FOR SOCIAL SECURITY

DISABILITY BENEIFT INFORMATIONWC7543 C2 03/09 DFS-F2-DWC-3 REQUEST FOR WAGE LOSS/TEMPORARY

PARTIAL BENEFITSWC9018 A 03/07 RPFB RESPONSE TO PETITION FOR BENEFITWC8133 F 01/15 DFS-F5-DWC-10 STATEMENT OF CHARGES FOR DRUGS

AND MEDICAL EQUIPMENT & SUPPLIESWC7752 B 03/09 DFS-F2-DWC-40 STATEMENT OF QUARTERLY EARNINGS

FOR SUPPLEMENTAL INCOME BENEFITSWC9529 D 01/08 DFSF5DWC250108 UNIFORM MEDICAL TREATMENT/

STATUS REPORTING FORMWC7673 E2 03/09 DFS-F2-DWC-1A WAGE STATEMENTWC8733 10/95 IA21095 WC SUBSEQUENT REPORT




GeorgiaWC9720 D 07/14 WC-131A ANNUAL INSURER UDPATEWC7869 Q 02/16 WC-25 APPLICATION FOR LUMP SUM /

ADVANCE PAYMENTWC9056 F 07/11 WC-15 ATTORNEY CERTIFICATION FOR NO

LIABILITY STIPULATIONSWC9061 E 07/17 WC108A ATTORNEY FEE APPROVALWC9060 F 07/17 WC102C ATTORNEY LEAVE OF ABSENCEWC9062 E 07/17 WC108B ATTORNEY WITHDRAWAL / LIENWC8640 G 07/11 WC-207 AUTHORIZATION AND CONSENT TO

RELEASE MEDICAL INFORMATIONWC7899 U 07/17 WC-4 CASE PROGRESS REPORTWC7767 G 07/11 WC-200A CHANGE OF PHYSICIAN/ADDITIONAL

TREATMENT BY CONSENTWC7587 S 07/14 WC-26 CONSOLIDATED YEARLY REPORT OF

MEDICAL-ONLY CASES AND ANNUALPAYMENTS ON INDEMNITY CLAIMS

WC8587 D 07/11 WC243 CREDITWC9174 G 02/16 WCR1CATEE EMPLOYEE'S REQUEST FOR

CATASTROPHIC DESIGNATIONWC7794 Z 07/17 WC-1 EMPLOYER'S FIRST REPORT OF INJURY

OR OCCUPATIONAL DISEASEWC9528 06/01 SIH0601 EMPLOYER'S KNOWLEDGE AFFIDAVIT

(SECOND INJURY FUND)WC9069 F 07/11 WCR2A INDIVIDUALIZED REHABILITATION

PLANWC9549 D 07/11 WC240A JOB ANALYSISWC8094 R 07/17 WC-20A MEDICAL REPORTWC9058 J 07/17 WC-102D MOTION/OBJECTION TO MOTIONWC7764 G 07/11 WC-121 NOTICE OF CHANGE OF TPA/SERVICING

AGENTWC8735 B 06/01 SIA0601 NOTICE OF CLAIMWC7751 R 02/16 WC-14 NOTICE OF CLAIM/REQUEST FOR

HEARING/REQUEST FOR MEDIATIONWC9067 F 07/14 WC-244 NOTICE OF INTENT TO BECOME A PARTY

AT INTERESTWC9064 F 07/14 WC-206 NOTICE OF INTENT TO BECOME A PARTY

AT INTERESTWC7925 Z 07/17 WC-2 NOTICE OF PAYMENT OR SUSPENSION

OF BENEFITSWC7853 W 07/17 WC-2A NOTICE OF PAYMENT OR SUSPENSION

OF DEATH BENEFITSWC9059 F 07/17 WC102B NOTICE OF REPRESENTATION OF ANY

PARTY OTHER THAN A CLAIMANT OREMPLOYEE BY AN ATTORNEY

WC7854 P 07/17 WC-3 NOTICE TO CONTROVERTWC7760 K 01/14 WC-104 NOTICE TO EMPLOYEE OF MEDICAL

RELEASE TO RETURN TO WORK WITHRESTRICTIONS OR LIMITATIONS

WC8754 J 07/14 WC-240 NOTICE TO EMPLOYEE OF OFFER OFSUITABLE EMPLOYMENT

WC9066 G 07/12 WC226B PETITION FOR APPOINTMENT OFTEMPORARY CONSERVATOR FORLEGALLY INCAPACITATED ADULT

WC9065 G 07/12 WC226A PETITION FOR APPOINTMENT OFTEMPORARY CONSERVATOR OFMINOR(S)

WC9994 07/17 WC-PMT PETITION FOR MEDICAL TREATMENTWC9964 D 02/16 WC-REHAB OBJECTION REHAB OBJECTIONWC9068 F 07/11 WCR2 REHABILITATION TRANSMITAL FORMWC8736 D 06/12 S.I. C REIMBURSEMENT REQUEST




WC9063 E 07/13 WC-205 REQUEST FOR AUTHORIZATIONOF TREATMENT OR TESTING BYAUTHORIZED MEDICAL PROVIDER

WC9637 D 02/16 WCCHANGEOFADDRESS REQUEST FOR CHANGE OF ADDRESSWC8588 F 07/11 WC-12 REQUEST FOR COPY OF BOARD

RECORDSWC9057 F 07/11 WC102 REQUEST FOR DOCUMENTS TO PARTIESWC9636 C 07/11 WCR5 REQUEST FOR REHAB CONFERENCEWC7881 M 02/16 WC-R1 REQUEST FOR REHABILITATIONWC9070 G 07/13 WC-R3 REQUEST FOR REHABILITATION

CLOSUREWC9548 F 07/17 WC-100 REQUEST FOR SETTLEMENT MEDIATIONWC9634 E 07/17 WC-14A REQUEST TO CHANGE INFORMATION ON

A PREVIOUSLY FILED FORM WC-14WC7775 J 07/14 WC-200B REQUEST/OBJECTION FOR CHANGE OF

PHYSICIAN/ADDITIONAL TREATMENTWC9635 D 07/11 WC-262 WAGE DOCUMENTATION OF

TEMPORARY PARTIAL DISABILITYPAYMENTS

WC7901 Q 07/17 WC-6 WAGE STATEMENTWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

HawaiiWC9240 03/92 WC30392 CARRIER'S CASE REPORTWC9242 A 10/05 WC51005 EMPLOYEE'S CLAIM FOR WORKERS'

COMPENSATION BENEFITSWC9577 B 01/18 WC141005 EMPLOYEE'S WAGE REPORT FOR FIFTY-

TWO WEEKS PRIOR TO DATE OF INJURYWC9246 A 09/16 WC-1 FIRST REPORT OF INJURYWC9948 03/05 WC-101 HIGHLIGHTS OF THE HAWAII WORKERS'

COMPENSATION LAWWC9576 A 10/05 WC21005 PHYSICIAN'S REPORTWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

IdahoWC9334 C 11/13 IC-1003 ANSWER TO COMPLAINTWC9264 E 09/15 RMR-4 CLAIMANT'S REQUEST FOR PERSONAL

WORKERS' COMPENSATION RECORDSWC8795 G 09/15 RMR-3 EMPLOYER CERTIFICATE AND CLAIMS

HISTORY RELEASE (FOR EMPLOYERSNOT SUBJECT TO THE A.D.A.)

WC8939 F 09/15 RMR-2 EMPLOYER CERTIFICATE AND CLAIMSHISTORY RELEASE (FOR EMPLOYERSSUBJECT TO THE A.D.A.)

WC8796 A 07/05 ICFORM140705 EMPLOYER'S SUPPLEMENTAL REPORTWC7556 C 08/13 IA-1 FIRST REPORT OF INJURY OR ILLNESSWC9976 12/13 INSTRUCTIONS FOR FILLING OUT THE

WC FIRST REPORT OF INJURYWC9337 06/03 MOTION FOR RECONSIDERATIONWC9338 06/03 MOTION TO PRESENT ADDITIONAL

EVIDENCEWC7860 A 05/02 FORM 8 NOTICE OF CLAIM STATUSWC8610 D 05/13 PETITION FOR CHANGE OF PHYSICIANWC9961 11/13 IC 9030 REHABILITATION REFERRAL FORMWC9638 09/05 ICFORM4321 REIMBURSEMENT FOR HEALTH CARE

TRAVEL EXPENSESWC9339 06/03 IC1022 REPORT OF LITIGATION EXPENSE

(CLAIMANT'S ATTORNEY)WC9340 06/03 IC1023 REPORT OF LITIGATION EXPENSES

(EMPLOYER/SURETY/ISIF/SELFINSURERS)

WC8799 D 01/15 IC36 REPORT OF OUTSTANDING AWARDSFOR FATAL, PERMANENT PARTIAL




IMPAIRMENT, AND PERMANENT TOTALDISABILITY CLAIMS

WC9335 B 04/09 REQUEST FOR APPROVAL OF DISPUTEDCHARGE

WC9341 06/03 REQUEST FOR MEDIATIONWC8794 K 09/15 RMR-1 REQUEST FOR WORKERS'

COMPENSATION RECORDSWC9336 06/03 RESPONSE TO MOTION FOR APPROVAL

OF DISPUTED CHARGEWC8611 D 05/13 RESPONSE TO PETITION FOR CHANGE OF

PHYSICIANWC9099 01/02 IC6F SUMMARY OF PAYMENTS - FATAL CASEWC8612 A 11/01 IC61101 SUMMARY OF PAYMENTS - NON-FATAL

CASESWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC9342 B 03/08 IC1001 WORKERS' COMPENSATION COMPLAINTWC9343 C 05/13 IC1002 WORKERS' COMPENSATION COMPLAINT

AGAINST THE INDUSTRIAL SPECIALINDEMNITY FUND (ISIF)

IllinoisWC8968 A 12/04 IC61204 APPEARANCE OF REPRESENTATIVEWC8807 D 05/12 IC01 APPLICATION FOR ADJUSTMENT OF

CLAIM (APPLICATION FOR BENEFITS)WC8811 C 08/12 IC41 ARBITRATION INFORMATION SHEETWC8188 V 08/12 FORM 45 EMPLOYER'S FIRST REPORT OF INJURYWC1567 M 08/12 FORM 85 EMPLOYER'S SUPPLEMENTARY REPORT

OF INJURYWC8986 B 03/06 IC320306 ILLINOIS WORKERS' COMPENSATION

COMMISSION NOTICE OF REJECTION OFSETTLEMENT CONTRACT

WC8982 A 12/04 IC271204 MOTION TO DISMISS ATTORNEY OFRECORD

WC8979 A 12/04 IC171204 MOTION TO VOLUNTARILY DISMISSWC8983 A 12/04 IC281204 MOTION TO WITHDRAW AS ATTORNEY

OF RECORDWC8967 C 04/11 IC4 NOTICE OF MOTION AND ORDERWC8980 A 12/04 IC191204 ORDER TO DISMISS CASE FOR WANT OF

PROSECUTIONWC8978 A 12/04 IC14D1204 ORDER TO DISMISS OR WITHDRAW

PETITION UNDER SECTION 19(B-1) OFTHE ACT

WC8969 A 12/04 IC71204 PETITION FOR AN IMMEDIATE HEARINGUNDER SECTION 19(B) OF THE ACT

WC8975 A 12/04 IC14A1204 PETITION FOR IMMEDIATE HEARINGUNDER SECTION 19(B-1) OF THE ACT

WC8973 A 12/04 IC11A1204 PETITION FOR REVIEW OF ARBITRATIONDECISION UNDER SECTION 19(B -1) OFTHE ACT

WC8974 A 12/04 IC141204 PETITION FOR REVIEW UNDER SECTION19(H) OR 8(A) OF THE ACT

WC8981 A 12/04 IC231204 PETITION TO REINSTATE CASEWC8809 A 12/04 IC151204 PROOF OF SERVICEWC8406 B 12/04 IC311204 REHABILITATION PLANWC8808 B 02/10 IC9 REQUEST FOR HEARINGWC8810 A 12/04 IC361204 REQUEST FOR VOLUNTARY

ARBITRATIONWC8970 A 12/04 IC81204 RESPONSE TO PETITION FOR AN

IMMEDIATE HEARING UNDER SECTION19(B) OF THE ACT

WC8976 A 12/04 IC14B1204




RESPONSE TO PETITION FOR IMMEDIATEHEARING UNDER SECTION 19(B-1) OFTHE ACT

WC8769 E 05/12 IC5 SETTLEMENT CONTRACT LUMP SUMPETITION AND ORDER

WC8984 C 08/12 IC29 STIPULATION TO SUBSTITUTEATTORNEY

WC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC9995 11/11 IA-2 WORKERS COMPENSATION

SUBSEQUENT REPORTIndiana

WC7704 B 04/12 SF 34873 AGREEMENT BETWEEN PARTIES FORLUMP SUM PAYMENT

WC7785 A 05/10 SF 18875 AGREEMENT TO COMPENSATIONBETWEEN THE DEPENDENTS OFDECEASED EMPLOYEE AND EMPLOYER

WC7701 C 03/09 SF 1043 AGREEMENT TO COMPENSATION OFEMPLOYEE AND EMPLOYER

WC7788 C 06/05 SF 29109 APPLICATION FOR ADJUSTMENT OFCLAIM

WC9782 B 01/15 SF18487 APPLICATION FOR ADJUSTMENT OFCLAIM FOR PROVIDER FEE

WC7783 A 02/98 SF 1042 APPLICATION FOR REVIEW BY FULLBOARD

WC8785 A 04/09 SF53913 EMPLOYEE WAIVER OF EXAMINATIONBY PERSONAL PHYSICIAN

WC7703 F 01/02 SF 34401 FIRST REPORT OF EMPLOYEE INJURY,ILLNESS

WC9778 B 07/12 SF 53914 NOTICE OF DENIAL OF BENEFITSWC7629 B 07/12 SF 48557 NOTICE OF INABILITY TO DETERMINE

LIABILITY/REQUEST FOR ADDITIONALTIME

WC9820 A 03/13 FORM 54217 NOTICE OF SUSPENSION OF MEDICALBENEFITS

WC7702 D 08/11 SF 2118 PHYSICIAN'S REPORTWC8335 J 01/14 FORM 38911 REPORT OF CLAIM STATUS/REQUEST

FOR INDEPENDENT MEDICALEXAMINATION

WC9448 A 05/06 454420506 REQUEST FOR ASSISTANCEWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

IowaWC8869 C 02/15 14-0021 AGREEMENT FOR SETTLEMENT (IOWA

CODE SECTION 85.35(2))WC8873 B 08/09 14-0037 APPLICATION AND CONSENT ORDER

FOR PAYMENT OF BENEFITS UNDERIOWA CODE SECTION 85.21

WC9352 07/99 1400750799 APPLICATION TO DEFER PAYMENT OFFILING FEES, FINANCIAL AFFIDAVITAND ORDER

WC8684 D 02/17 14-0043 AUTHORIZATION FOR RELEASE OFINFORMATION REGARDING CLAIMANTSSEEKING WC BENEFITS

WC8870 A 07/05 1400230705 CHECKLIST - AGREEMENT FORSETTLEMENT

WC8926 A 07/05 1400270705 CHECKLIST - COMPROMISESETTLEMENT [IOWA CODE SECTION85.35]

WC8924 C 07/05 1400150705 CHECKLIST - FULL COMMUTATIONWC8943 B 07/05 1400190705 CHECKLIST - PARTIAL COMMUTATIONWC9705 A 07/12 14-0171 CLAIMANT'S CONFIDENTIAL

INFORMATION FORM




WC9620 B 07/12 14-0163 CLAIMANT'S STATEMENT (FOR NON-REPRESENTED CLAIMANT ONLY)

WC9618 A 02/15 14-0159 COMBINATION SETTLEMENT (IOWACODE SECTION 85.35 (4))

WC8925 D 01/17 14-0025 COMPROMISE SETTLEMENT [IOWACODE SECTION 85.35(3)]

WC9619 A 02/15 14-0161 CONTINGENT SETTLEMENTWC8871 G 07/17 14-0083 COPY / INFORMATION REQUESTWC9859 A 05/15 FORM 14-0001 FIRST REPORT OF INJURY OR ILLNESSWC9579 A 06/14 HEARING REPORTWC9171 03/00 1401410300 MEDICAL REPORT TRANSMITTAL FORMWC8868 D 07/09 FORM 100 ORIGINAL NOTICE AND PETITIONWC8923 E 03/18 FORM 9 ORIGINAL NOTICE AND PETITION AND

ORDER FOR COMMUATION OF ALLREMAINING BENEFITS OF 10 WEEKS ORMORE 876 IAC 6.2(6)

WC8919 F 03/18 FORM 9A ORIGINAL NOTICE AND PETITION ANDORDER FOR PARTIAL COMMUTATION

WC8922 C 11/06 1400111106 ORIGINAL NOTICE, PETITION, ANDANSWER CONCERNING APPLICATIONFOR ALTERNATE MEDICAL CARE

WC8793 D 01/09 FORM 100A ORIGINAL NOTICE, PETITION,ANSWER AND ORDER CONCERNINGINDEPENDENT MEDICAL EXAMINATION

WC8921 C 11/06 1400091106 ORIGINAL NOTICE, PETITION, ANSWERAND ORDER CONCERNING VOCATIONALREHABILITION PROGRAM BENEFIT

WC9071 C 10/10 14-0147 PAYMENT ACTIVITY REPORTWC9631 07/05 1401690705 WAIVER FOR RELEASE OF RECORDSWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

KansasWC9353 F 03/14 K-WC E-1 APPLICATION FOR HEARINGWC9356 G 03/14 K-WC E-4 APPLICATION FOR POST AWARD

MEDICALWC9354 G 03/14 K-WC E-3 APPLICATION FOR PRELIMINARY

HEARINGWC9357 G 03/14 K-WC E-5 APPLICATION FOR REVIEW AND

MODIFICATIONWC7564 K 11/16 K-WC 27-A INFORMATION FOR INJURED

EMPLOYEES (ENGLISH)WC7873 H 11/16 K-WC 270-A INFORMATION FOR INJURED

EMPLOYEES (SPANISH)WC8023 K 01/94 KWCFORMG1193 PHYSICIANS REPORT BLANKWC9351 C 11/16 KW-C-139 PRETRIAL STIPULATIONSWC8569 M 03/14 K-WC 97 REQUEST FOR WORKERS

COMPENSATION RECORDSWC8798 J 04/13 K-WC 970 REQUEST FOR WORKERS

COMPENSATION RECORDS (SPANISH)WC8059 K 11/16 K-WC FORM D SETTLEMENT AGREEMENT FINAL

RECEIPT AND RELEASE OF LIABILITYWC9410 D 10/12 K-WC 160 STATEMENT REGARDING ATTORNEY

FEESWC9355 F 03/14 K-WC E-2 SURVIVING SPOUSE, DEPENDENT OR

HEIR APPLICATION FOR HEARINGWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC8480 M 05/15 K-WC 25 WORKERS COMPENSATION

INFORMATION FOR KANSASEMPLOYERS AND EMPLOYEES(ENGLISH)

WC8481 M 05/15 K-WC 250 WORKERS COMPENSATIONINFORMATION FOR KANSAS




EMPLOYERS AND EMPLOYEES(SPANISH)

WC8570 P 03/14 K-WC 98 WORKER'S REQUEST FOR WORKERSCOMPENSATION RECORDS

WC8568 D 02/06 KWC150206 WRITTEN CLAIM FOR WORKERSCOMPENSATION

KentuckyWC1520 E 10/16 FORM 110-I AGREEMENT AS TO COMPENSATION

AND ORDER APPROVING SETTLEMENTWC1521 E 10/16 FORM 110ODHLCWP AGREEMENT AS TO COMPENSATION

AND ORDER APPROVING SETTLEMENT- HEARING LOSS/OCCUPATIONALDISEASE

WC1583 D 10/16 FORM 103 APPLICATION FOR RESOLUTION OFHEARING LOSS CLAIM

WC1581 D 10/16 FORM 101 APPLICATION FOR RESOLUTION OFINJURY CLAIM

WC1582 D 10/16 FORM 102-OD APPLICATION FOR RESOLUTION OFOCCUPATIONAL DISEASE CLAIM

WC9345 03/95 FORM1090395 ATTORNEY FEE ELECTIONWC1572 A 10/16 FORM SHL HEARING LOSS STIPULATION AND

CONTESTED ISSUESWC1527 E 10/16 FORM 112 MEDICAL DISPUTEWC1585 A 04/05 FORM 108-HL MEDICAL REPORT - HEARING LOSSWC1559 F 10/16 FORM 107 MEDICAL REPORT - INJURYWC1561 D 04/05 FORM 107-P MEDICAL REPORT - PSYCHOLOGICALWC1515 D 07/03 FORM 106 MEDICAL WAIVER AND CONSENT

(KENTUCKY)WC9344 A 10/16 MTR20702 MOTION TO REOPEN KRS 342.732

BENEFITSWC9346 C 10/16 FORM 11 MOTION TO SUBSTITUTE PARTY AND

CONTINUE BENEFITSWC1577 B 10/16 FORM 111 NOTICE OF CLAIM DENIAL OR

ACCEPTANCE (OCCUPATIONALDISEASE)

WC8529 A 03/03 FORM1130303 NOTICE OF DESIGNATED PHYSICIANWC1580 A 10/16 FORM SOD OCCUPATIONAL DISEASE STIPULATION

AND CONTESTED ISSUESWC1514 D 10/16 FORM 105 PLAINTIFF'S CHRONOLOGICAL MEDICAL

HISTORYWC1513 D 10/16 FORM 104 PLAINTIFF'S EMPLOYMENT HISTORYWC1573 09/97 FORM 114 REQUEST FOR PAYMENT FOR

SERVICES OR REIMBURSEMENT FORCOMPENSABLE EXPENSES

WC1586 01/97 FORM 115 SOCIAL SECURITY RELEASE FORMWC1579 A 10/16 FORM SI STATEMENT OF PROPOSED

STIPULATIONS AND NOTICE OFCONTESTED ISSUES (INJURYSTIPULATION)

WC8720 B 10/16 AWW-1 WAGE CERTIFICATIONLouisiana

WC9562 F 09/17 SIB FORM B DISABILITY BENEFITS PROVIDED TOINJURED EMPLOYEE

WC8487 F 04/14 LWC-WC-1008 DISPUTED CLAIM FOR COMPENSATIONWC9846 B 12/14 LWC-WC 1009 DISPUTED CLAIM FOR MEDICAL

TREATMENTWC1010 08/17 LWC-WC-1151 EMPLOYEE AUTHORIZATION FOR OWCA

TO RELEASE CONFIDENTIAL WORKERS’COMPENSATION RECORDS

WC8288 C 07/08 LWC-WC-1025.EE EMPLOYEE CERTIFICATE OFCOMPLIANCE




WC9851 12/00 LDOL-WC 1025.EE EMPLOYEE CERTIFICATE OFCOMPLIANCE (SPANISH)

WC8289 C 07/08 LWC-WC 1020 EMPLOYEE'S MONTHLY REPORT OFEARNINGS

WC9850 07/08 LWC-WC 1020 EMPLOYEE'S MONTHLY REPORT OFEARNINGS (SPANISH)

WC8290 B 07/08 LWC-WC-1026 EMPLOYEE'S QUARTERLY REPORT OFEARNINGS

WC1517 A 07/08 LWC-WC-1025.ER EMPLOYER CERTIFICATE OFCOMPLIANCE (MUST BE INCLUDEDWITH WC8486D EMPLOYER REPORT OFINJURY/ILLNESS)

WC8486 G 01/14 LWC-WC IA-1 EMPLOYER REPORT OF INJURY/ILLNESSWC9879 04/12 LWC FORM 1010 FIRST REQUESTWC9849 07/08 GLOSSARY OF TERMS FOR QUARTERLY

REPORT 1017AWC8516 A 07/08 WC1005A MOTION FOR RECOGNITION OF RIGHT

TO SOCIAL SECURITY OFFSETWC8835 01/09 SIB FORM A NOTICE OF CLAIM WITH SECOND

INJURY FUNDWC8483 H 09/14 LWC-WC-1002 NOTICE OF PAYMENTWC8517 A 07/07 LWC-WC-1005B ORDER RECOGNIZING RIGHT TO SOCIAL

SECURITY OFFSETWC9497 A 07/08 LWC-WC 1121 PHYSICIAN CHOICE FORMWC8428 C 07/08 WC10110708 REQUEST FOR COMPROMISE OR LUMP

SUM SETTLEMENTWC8430 E 10/14 LWC-WC 1015 REQUEST FOR INDEPENDENT MEDICAL

EXAMINATIONWC8426 C 07/08 LWC -WC-1004 REQUEST FOR SOCIAL SECURITY

BENEFITS INFORMATIONWC9358 01/98 REQUEST FOR WAIVER OF PAYMENT OF

ADVANCE COSTS FACTS CONCERNINGTHE EMPLOYEE

WC9878 B 06/15 FORM 1010 REQUEST OF AUTHORIZATION/CARRIEROR SELF INSURED EMPLOYER RESPONSE

WC8484 E 07/08 LWC-WC-1003 STOP PAYMENT FORMWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC1009 08/17 LWC-WC-1150 WORKERS’ COMPENSATION RECORDS

REQUEST FORMMaine

WC7588 F 01/13 WCB-2C APPLICATION FOR WAIVERWC7590 C 01/14 WCB-6 CERTIFICATE AUTHORIZING RELEASE

OF BENEFIT INFORMATION (COPIES FOREMPLOYEE, INSURER, EMPLOYER)

WC7987 A 01/13 WCB 8 CERTIFICATE OF DISCONTINUANCE ORREDUCTION OF COMPENSATION

WC7947 C 01/13 WCB-4A CONSENT BETWEEN EMPLOYER ANDEMPLOYEE

WC7946 E 01/13 WCB 4 DISCONTINUANCE OR MODIFICATIONOF COMPENSATION

WC9132 A 01/13 WCB 121 EMPLOYEE PETITION FOR REVIEWOF INCAPACITY AND REQUEST FORPROVISIONAL ORDER

WC9857 A 01/13 WCB-231A EMPLOYEE'S RETURN TO WORK REPORT(RULE 8.15)

WC7991 A 01/13 WCB 231 EMPLOYEE'S RETURN TO WORK REPORT(WITH NOTICE TO EMPLOYER, INSURERAND TO EMPLOYEE) (4 PART CARBONSET, ONE COPY EACH FOR W.C. BOARD,EMPLOYEE, INSURER AND EMPLOYER)

WC7808 F 01/13 WCB-1




EMPLOYER'S FIRST REPORT OFOCCUPATIONAL INJURY OR DISEASE

WC1594 B 12/94 WCB-12 EMPLOYER'S SUPPLEMENTAL REPORTWC7990 A 01/13 WCB 230 EMPLOYMENT STATUS REPORTWC9902 01/13 WCB-2B FRINGE BENEFITS WORKSHEETWC7739 F 10/15 WCB-220 LIMITED CERTIFICATE AUTHORIZING

WRITTEN RELEASE OF MEDICAL /HEALTH CARE INFORMATION

WC7593 D 10/15 WCB-10 LUMP SUM SETTLEMENTWC7812 F 01/13 WCB-3 MEMORANDUM OF PAYMENTWC8277 A 01/13 WCB 25 MOTION FOR AWARD OF FEES AND

DISBURSEMENTSWC7988 D 01/13 WCB 90506 NOTICE OF CONTROVERSYWC9134 A 01/13 WCB 140 PETITION FOR AWARD OF

COMPENSATIONWC9135 A 01/13 WCB 150 PETITION FOR AWARD OF

COMPENSATION—FATALWC9136 A 01/13 WCB 160 PETITION FOR AWARD OF

COMPENSATION—OCCUPATIONALDISEASE LAW

WC8699 B 10/15 WCB-190 PETITION FOR PAYMENT OF MEDICALAND RELATED SERVICES

WC9138 A 01/13 WCB 171 PETITION FOR REINSTATEMENTWC9137 A 01/13 WCB 170 PETITION FOR RESTORATIONWC9131 06/98 WCB1200698 PETITION FOR REVIEW OF INCAPACITYWC9131 A 01/13 WCB 120 PETITION FOR REVIEW OF INCAPACITYWC9133 A 01/13 WCB 122 PETITION TO DETERMINE AVERAGE

WEEKLY WAGEWC9903 01/13 WCB-321 PETITION TO DETERMINE ENTITLEMENT

TO REHABILITATION SERVICESWC9139 A 01/13 WCB 180 PETITION TO DETERMINE EXTENT OF

PERMANENT IMPAIRMENTWC9140 A 01/13 WCB 195 PETITION TO REMEDY DISCRIMINATIONWC8272 C 06/17 M-1 PRACTITIONER'S REPORTWC8700 A 01/13 WCB 190A PROVIDER'S PETITION FOR PAYMENT OF

MEDICAL AND RELATED SERVICESWC7992 A 01/13 WCB 250 REQUEST FOR EXPEDITED PROCEEDINGWC7852 C 10/15 WCB M-2 REQUEST FOR INDEPENDENT MEDICAL

EXAMINATIONWC8701 A 11/02 WCB3000598 REQUEST FOR REVIEW OF HEARING

OFFICER'S DECISIONWC7807 B 01/13 WCB-2A SCHEDULE OF DEPENDENT(S) AND

FILING STATUS STATEMENTWC9375 06/03 WCC26 STATEMENT OF INCURRED LEGAL FEES

(CONTESTED CASES)WC7811 D 01/13 WCB-2 WAGE STATEMENTWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC9609 04/05 WORKERS' COMPENSATION REPORTING

FORMMaryland

WC9667 A 03/06 AGREEMENT OF FINAL COMPROMISEAND SETTLEMENT

WC9806 A 04/14 WCC FORM VR06 AGREEMENT ON THE PROPRIETYOF SERVICES AND SELECTION OFPRACTITIONER

H10 10/17 H-10 APPLICATION FOR LUMP SUMA25 06/15 A-25 AUTHORIZATION FOR RELEASE OF

MEDICAL INFORMATIONWC9732 10/07 C-18 CERTIFICATION OF FUNERAL EXPENSESWC9731 10/07 C-3 CLAIM AMENDMENTC51 03/14 C51




CLAIM FOR MEDICAL SERVICES(AVAILABLE ELECTRONICALLY INPDF FORMAT ONLY, DUE TO DEFAULTAREAS)

H05 12/09 H-05 CLAIMANT'S AFFIDAVIT IN SUPPORT OFSETTLEMENT

WC9734 10/07 H-44 CLAIMANT'S CONSENT TO PAYATTORNEY AND DOCTOR FEES

WC8745 E 03/18 H44 CLAIMANT'S CONSENT TO PAYATTORNEY FEE AND DOCTOR FEES

WC9012 A 05/10 VR02 CLOSURE REPORT-REHABILITATIONOFFICE

WC9796 A 03/14 H-32 CONTROVERSION OF MEDICAL CLAIMWC9733 10/07 C-35 DEPENDENT'S CLAIM FOR DEATH

BENEFITSWC9011 11/00 VR71100 INITIAL REHABILITATION SERVICES

REFERRAL FORMWC9945 C 06/17 C-10 INSURER’S TERMINATION OF MEDICAL

BENEFITS(New) WC8743 D 01/18 H24R ISSUES

WC8726 C 04/14 WCC FORM VR13R NOTICE OF VOCATIONALREHABILITATION PLANCONTROVERSION OR ACCEPTANCE

C25R 03/18 C25R NOTICE TO WITHDRAW APPEARANCEVR01 04/14 WC FORM VR01 PROPOSED VOC REHAB PLANWC9613 09/95 FORMR330995 REHABILITATION PROGRESSC90R 02/09 C90R REQ FOR DOC CORR

(New) H25R 05/18 H25R REQUEST ACTION FILED ISSUE -MARYLAND

H31R 01/16 H31R REQUEST FOR CHANGE OF ADDRESS -MARYLAND

(New) H28R 05/18 H28R REQUEST FOR CONTINUED HEARING -MARYLAND

H26R 03/12 H26R REQUEST FOR EMERGENCY HEARINGWC9038 06/09 H23R REQUEST FOR EMPLOYER DESIGNEE TO

RECEIVE NOTICE OF EMPLOYEE CLAIMSH30R 07/05 H30R REQUEST FOR RECONSID/MODIFH27R 09/03 H27R0903REV REQUEST FOR REHEARING - MARYLANDH35R 02/07 H35R REQUEST HEARINGH29R 08/03 H29R REQUEST POSTPONED EMERGERGENCY

HEARINGC26R 01/10 C26R REQUEST TO ENTER APPEARANCEC24R 01/18 C24R REQUEST TO ENTER APPEARANCEH33R 10/16 H-33R REQUEST TO IMPLEAD A PARTYWC8741 04/97 FORMVR50R0497 RESPONSE TO SHOW CAUSE ORDER

(VOCATIONAL REHABILITATION)WC9982 A 02/17 H07R SETTLEMENT WORKSHEETWC9737 C 10/16 C-2 STATEMENT OF WAGE INFORMATIONC50R 10/17 C50R STIPULATION FOR ADVANCEMENTH34 04/18 H-34 STIPULATION OF PARTIES AND AWARD

OF COMPENSATIONH08 01/15 H08 SUBPOENA/SUBPOENA DUCES TECUMWC8739 B 07/11 SF2 SURGEON'S REPORTWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

MassachusettsWC8164 D 01/15 FORM 116B ADDENDUM TO LUMP SUM SETTLEMENT

AGREEMENT PURSUANT TO M.G.L. C. 398S 75 OF THE ACTS OF 1991, EFFECTIVEDECEMBER 23, 1991-VOCATIONALREHABILITATION STATUS

WC8952 A 07/10 FORM 132




AFFIDAVIT IN SUPPORT OF EMPLOYEE'SREQUEST FOR SPEEDY CONFERENCEBECAUSE OF HARDSHIP

WC8946 A 07/10 FORM 112A AFFIDAVIT IN SUPPORT OF REQUESTFOR WAIVER OF FILING FEE UNDER SEC.11C

WC9194 A 07/10 FORM 153 AFFIDAVIT OF EXEMPTION FORCERTAIN CORPORATE OFFICERS ORDIRECTORS

WC8954 B 07/13 FORM 136 AFFIDAVIT OF INDIGENCE ANDREQUEST FOR WAIVER OF SS11A(2) FEES

WC8948 C 06/17 FORM 117 AGREEMENT FOR REDEEMINGLIABILITY BY LUMP SUM UNDER G.L.CH. 152 FOR INJURIES OCCURING ON ORAFTER NOV. 1, 1986

WC8949 B 07/13 FORM 117A AGREEMENT FOR REDEEMINGLIABILITY BY LUMP SUM UNDERG.L. CH. 152. SEC.48 FOR INJURIESOCCURRING BEFORE NOV. 1, 1986

WC8950 B 07/13 FORM 121A AGREEMENT THAT NO IMPARTIALPHYSICIAN REPORT IS REQUIRED

WC8507 F 02/17 FORM 105 AGREEMENT TO EXTEND 180 DAYPAYMENT WITHOUT PREJUDICE PERIOD

(New) WC8513 J 05/15 FORM 113 AGREEMENT TO PAY COMPENSATIONWC7515 F 10/16 FORM 123 AGREEMENT UNDER SECTION 37 OR 37AWC8958 D 07/13 FORM 152 AMENDMENT/SUSPENSION OR CLOSURE

OF VOCATIONAL REHABILITATIONPLAN

WC8520 E 08/15 FORM 121 APPEAL OF CONFERENCE PROCEEDINGWC8512 D 07/13 FORM 112 APPEAL TO REVIEWING BOARDWC9633 B 08/13 FORM-127 AVERAGE WEEKLY WAGE

COMPUTATION SCHEDULEWC9455 11/03 CASE REVIEW FORMWC9454 11/03 CERTIFIED VENDOR QUARTERLY

REPORT FOR O.E.V.R.WC9765 10/07 COLA REIMBURSEMENT REQUESTWC8955 E 11/17 FORM 140 CONFERENCE MEMORANDUMWC8150 C 07/13 FORM 116A CONSENT OF EMPLOYER TO LUMP SUM

SETTLEMENTWC8962 B 08/05 DIA FILE REQUESTWC8959 A 07/10 FORM 160 EMPLOYEE BIOGRAPHICAL DATAWC8522 D 07/13 FORM 110 EMPLOYEE'S CLAIMWC7796 D 07/13 FORM 126 EMPLOYEE'S EARNING REPORTWC8960 B 07/10 FORM 161 EMPLOYEE'S HEARING MEMORANDUMWC8888 B 07/10 FORM 134 HEALTH CARE PROVIDER COMPLAINTWC8957 D 02/14 FORM 151 INDIVIDUAL WRITTEN REHABILITATION

PROGRAMWC9457 F 05/15 INSURANCE INQUIRY FORMWC9251 D 07/14 INSURER REQUEST CERTIFICATIONWC8510 E 07/13 FORM 108 INSURER'S COMPLAINT FOR

MODIFICATION, DISCONTINUANCE ORRECOUPMENT OF COMPENSATION

WC8961 C 07/13 FORM 162 INSURER'S HEARING MEMORANDUMWC8509 D 07/13 FORM 107 INSURER'S NOTIFICATION OF

ACCEPTANCE, RESUMPTION ORTERMINATION OR MODIFICATION OFWEEKLY COMPENSATION

WC8506 D 07/13 FORM 104 INSURER'S NOTIFICATION OF DENIALWC8505 E 07/10 FORM 103 INSURER'S NOTIFICATION OF PAYMENTWC8508 D 07/13 FORM 106 INSURER'S NOTIFICATION OF

TERMINATION OR MODIFICATION OF




WEEKLY COMPENSATION DURINGPAYMENT WITHOUT PREJUDICE PERIOD

WC8956 B 07/13 FORM 141 LAST BEST OFFER AT CONFERENCEWC8167 B 07/10 FORM 116C LEIN DISCLOSURE FORMWC9643 B 07/10 MILEAGE EXPENSE VOUCHERWC9717 B 07/13 FORM 125 MOTION FOR EXPEDITED CONFERENCEWC8514 C 07/10 FORM 114 NOTICE OF CHANGE / APPEARANCE OF

COUNSELWC7724 B 07/10 FORM 124A NOTIFICATION OF ARBITRATION

AWARDWC8511 D 07/13 FORM 109 NOTIFICATION OF WITHDRAWL OF

CLAIM OR COMPLAINTWC9453 A 03/07 OEVR REFERRAL FORM (FOR ALL

PARTIES FOR MANDATORY MEETINGS)WC9229 C 07/13 FORM 46A REQUEST FOR §46A CONFERENCE IN

CONJUNCTION WITH LUMP SUM UNDER§48

WC8515 E 07/13 FORM 116 REQUEST FOR LUMP SUM CONFERENCEWC7514 D 07/10 FORM 122 REQUEST FOR SECTION 37 OR 37A

PROCEEDINGWC8951 C 07/13 FORM 131 REQUEST FOR SPEEDY CONFERENCE

BECAUSE OF HARDSHIPWC9933 A 08/14 FORM 19 SECTION 19 AGREEMENTWC9456 A 05/12 CR-28 STATE OF MASSACHUSETTS WORKERS'

COMPENSATION COLA DATA FORMWC8947 B 07/13 FORM 115 THIRD PARTY CLAIM / NOTICE OF LIENWC8953 E 10/10 FORM-133A UTILIZATION REVIEW AGENT AND

QUALITY ASSESSENT PROGRAMCOMPLAINT FORM

WC8733 10/95 IA21095 WC SUBSEQUENT REPORTMichigan

WC9383 C 04/12 WC-119 AFFIDAVIT IN SUPPORT OF REDEMPTION(SETTLEMENT) AGREEMENT

WC9384 A 06/08 WC-119(SP) AFFIDAVIT IN SUPPORT OF REDEMPTION(SETTLEMENT) AGREEMENT (SPANISH)

WC9388 B 05/12 WC-556 AGREEMENT TO REDEEM LIABILITYWC9389 A 06/08 WC-556(SP) AGREEMENT TO REDEEM LIABILITY

(SPANISH)WC9460 B 12/11 WC-728 AMPUTATION CHARTWC9230 B 11/11 WC-108 APPLICATION FOR ADVANCE PAYMENTWC7864 C 02/13 WC-104A APPLICATION FOR MEDIATION OR

HEARING – FORM AWC7821 F 02/17 WC-104C APPLICATION FOR MEDIATION OR

HEARING - FORM CWC8715 D 01/14 FA-112 APPLICATION FOR REIMBURSEMENT

(FUNDS ADMINISTRATION)WC7862 F 11/11 WC-114 APPLICATION FOR REIMBURSEMENT

FROM THE COMPENSATIONSUPPLEMENT FUND

WC9191 B 01/14 WC-271 APPLICATION FOR REIMBURSEMENTFROM THE MEDICAL BENEFITS FUND

WC9266 D 02/12 WC739 CARRIER’S EXPLANATION OF BENEFITSWC7936 C 04/12 WC-251 CARRIER'S RESPONSEWC7938 C 04/12 WC-262 CLAIM/CROSS-CLAIM FOR REVIEWWC9189 D 04/13 WC-117 EMPLOYEE'S REPORT OF CLAIMWC7819 K 02/13 WC-100 EMPLOYER'S BASIC REPORT OF INJURYWC7820 N 09/13 WC-104B HEALTH CARE SERVICES APPLICATION

FOR MEDIATION OR HEARINGWC7971 H 02/13 WC-701 NOTICE OF COMPENSATION PAYMENTSWC7823 J 02/13 WC107 NOTICE OF DISPUTEWC9190 C 01/12 WC-117H




PROVIDER’S REPORT OF CLAIM &REQUEST FOR MEDICAL PAYMENT

WC9381 C 04/12 WC-113 REDEMPTION ORDERWC9382 B 06/08 WC-113 (SP) REDEMPTION ORDER (SPANISH)WC7824 D 11/11 WC-110 REPORT ON REHABILITATIONWC7822 C 10/11 WC-106 SUPPLEMENTAL REPORT OF FATAL

INJURYWC7935 G 03/14 WC-115 VOLUNTARY PAYMENT FORMWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC9385 C 05/12 WC-544 WORKER’S SETTLEMENT STATEMENTWC9386 A 06/08 WC-544(SP) WORKER'S SETTLEMENT STATEMENT

(SPANISH)Minnesota

WC9394 C 04/12 MNAS01 AFFIDAVIT OF SIGNIFICANT FINANCIALHARDSHIP

WC8293 J 09/15 MN AR04 ANNUAL CLAIM FOR REIMBURSEMENTFROM THE SECOND INJURY FUND

WC8343 M 09/15 MN AC03 ANNUAL CLAIM FOR REIMBURSEMENTOF SUPPLEMENTARY BENEFITS

WC9227 C 06/11 MN FE0005 AUTHORIZATION FOR FILE REVIEWOR RELEASE OF COPIES OF WORKERS’COMPENSATION CLAIM FILE

WC8848 D 07/10 MN BA01 BENEFIT ADDENDUMWC9556 B 04/12 MNCP03 CLAIM PETITION FOR DEPENDENCY

BENEFITS OR PAYMENT TO ESTATEWC9267 E 09/12 MNDS01 DISABILITY STATUS REPORTWC8087 J 11/12 MN RT01 EMPLOYEE OR INSURER'S OBJECTION TO

REQUESTED ATTORNEY FEES AND/ORCOSTS

WC9559 B 04/12 MNEC040508 EMPLOYEE'S CLAIM PETITIONWC9392 D 09/15 MN ED02 EMPLOYEE'S OBJECTION TO

DISCONTINUANCEWC8849 J 01/17 EQ05 EMPLOYEE'S REQUEST FOR

ADMINISTRATIVE CONFERENCEWC9642 D 09/15 MN-PF04 EXCESS FEE EXHIBITWC7595 Y 03/16 MN FR01 FIRST REPORT OF INJURYWC8407 K 04/14 MN HC01 HEALTH CARE PROVIDER REPORTWC8058 H 07/10 MN IS03 INTERIM STATUS REPORTWC9969 07/15 LONG-TERM TREATMENT WITH OPIOID

ANALGESIC MEDICATIONWC8451 J 04/12 MN MQ03 MEDICAL REQUESTWC8444 J 04/12 MN MR03 MEDICAL RESPONSEWC8850 B 06/09 MINNESOTA WORKERS' COMPENSATION

SYSTEM EMPLOYEE INFORMATIONSHEET

WC7589 B 06/09 MINNESOTA WORKERS' COMPENSATIONSYSTEM EMPLOYEE INFORMATIONSHEET (SPANISH)

WC9612 C 10/15 MN NO0016 NOTICE OF APPEAL TO WORKERS'COMPENSATION COURT OF APPEALS

WC9391 C 04/12 MNNA03 NOTICE OF APPEARANCE OF ATTORNEYFOR EMPLOYEE

WC8234 Q 04/17 MN NB01 NOTICE OF BENEFIT PAYMENTWC8467 J 09/15 MN NC01 NOTICE OF BENEFIT REINSTATEMENT

(New) WC8449 N 05/18 MN BD02 NOTICE OF DISCONTINUANCE OFWORKERS' COMPENSATION BENEFITSUPON DEATH OF EMPLOYEE

WC8042 M 02/10 MN DB02 NOTICE OF DISCONTINUANCEOF WORKERS' COMPENSATIONDEPENDENCY BENEFITS

WC8455 E 05/08 MN NF01 NOTICE OF FILE CLOSING




WC8466 K 02/10 MN NL01 NOTICE OF INSURER'S PRIMARYLIABILITY DETERMINATION

WC8262 G 09/15 MN RS05 NOTICE OF INTENTION TO CLAIMREIMBURSEMENT FROM THE SECONDINJURY FUND

WC8231 S 01/17 MN ND01 NOTICE OF INTENTION TO DISCONTINUEWORKERS' COMPENSATION BENEFITS

WC9632 D 10/14 NO0015 NOTICE OF PENALTY PAYMENTWC9427 A 05/08 MNCE00030508 OBJECTION TO PENALTY ASSESSMENTWC9255 E 09/08 MN JA04 ON THE JOB TRAINING PLANWC8452 H 09/15 MN PA04 PERMANENT TOTAL DISABILITY

AGREEMENTWC9393 07/01 LI23042040701 PETITION FOR DISPUTED OR EXCESS

ATTORNEY'S FEES AND/OR NON-REIMBURSED DISBURSEMENTS

WC9557 A 05/08 MNPT030508 PETITION FOR TAXATION OF ACTUALAND NECESSARY DISBURSEMENTSBEFORE

WC8864 H 01/14 MN PR01 PLAN PROGRESS REPORTWC8459 R 08/15 MN RE01 R-2 REHABILITATION PLANWC8460 Q 08/15 MN RP01 R-3 REHABILITATION PLAN

AMENDMENTWC7659 M 11/13 MN NR01 R-8 NOTICE OF REHABILITATION PLAN

CLOSUREWC8865 J 05/16 MN RC01 REHABILITATION CONSULTATION

REPORTWC7532 N 04/12 MN RQ03 REHABILITATION REQUESTWC7533 M 04/12 MN RR03 REHABILITATION RESPONSEWC8453 N 10/13 MN IW05 REHABILITATION RIGHTS AND

RESPONSIBILITIES OF THE INJUREDWORKER

WC8734 E 05/17 MN RW01 REPORT OF WORK ABILITYWC8066 H 07/10 MN QE03 REQEUST FOR EXTENSIONWC9608 C 04/12 CA0022 REQUEST FOR CERTIFICATION OF

DISPUTEWC9256 F 01/14 MN EP04 RETRAINING PLANWC8345 C 07/01 LI20324010701 SMALL CLAIMS COURT STATEMENT OF

CLAIMWC9558 F 06/14 SA04 STATEMENT OF ATTORNEY FEES AND

COSTSWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC8589 07/98 WORKERS' COMPENSATION CERTIFIED

MANAGED CARE PLAN ENDORSEMENTWC8590 07/98 WORKERS' COMPENSATION

UNCERTIFIED MANAGED CAREENDORSEMENT

MississippiWC9360 A 03/08 MWCCB5220308 ANSWERWC7920 B 01/03 MWCCFORMB190103 APPLICATION FOR LUMP SUM PAYMENTWC7684 02/92 R-1 EARLY NOTIFICATION OF SEVERE

INJURYWC7927 10/94 FORMB52 EMPLOYER'S NOTICE OF

CONTROVERSIONWC7642 E 08/01 IA10801 FIRST REPORT OF INJURY OR ILLNESSWC7644 D 06/96 B-927 MEDICAL REPORT (FOR PRELIMINARY,

PROGRESS OR FINAL REPORTWC7653 H 01/14 MWCCFORMB-31 NOTICE OF FINAL PAYMENTWC7866 A 07/96 MWCCFORMB180796 PAYMENT REPORTWC9359 A 03/08 MWCCB5110308 PETITION TO CONTROVERTWC9361 B 01/06 PREHEARING STATEMENT OF

CLAIMANT/EMPLOYER CARRIER




WC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC9362 04/00 FORM8C0400 WORKERS' COMPENSATION NOTICE

OF APPEAL TO MISSOURI COURT OFAPPEALS

MissouriWC7883 H 06/15 WC-22 ANSWER TO CLAIM FOR COMPENSATIONWC9935 A 06/15 WC-22-A ANSWER TO CLAIM FOR COMPENSATION

(INJURIES ON/AFTER 1/1/2014)WC9044 F 03/12 WC-MD-01 APPLICATION FOR DIRECT PAYMENTWC9046 D 08/11 WC-MD-03 APPLICATION FOR EVIDENTIARY

HEARINGWC9045 H 09/14 WC-MD-02 APPLICATION FOR PAYMENT OF

ADDITIONAL REIMBURSEMENT OFMEDICAL FEES

WC9039 C 08/14 WCT1 APPLICATION FOR TORT VICTIMS'COMPENSATION

WC8211 C 03/12 WC-43 AUTHORIZATION TO INSPECT AND/ORCOPY MEDICAL RECORDS

WC9442 B 03/12 WC-126 AUTHORIZATION TO RELEASEINFORMATION

WC8797 H 06/15 WC-21 CLAIM FOR COMPENSATION (FORINJURIES PRIOR TO JANUARY 1, 2014)

WC9926 B 06/15 WC-21-A CLAIM FOR COMPENSATION (INJURIESON/AFTER 1/1/2014)

WC9522 B 03/12 WC-9 MEDICAL TREATMENT FORMWC8392 V 06/17 WC-2 NOTICE OF COMMENCEMENT/

TERMINATION OF COMPENSATIONWC9042 B 10/11 WCR-1A PHYSICIAN'S REHABILITATION

INFORMATION SHEETWC8391 T 02/16 WC-1-EDI REPORT OF INJURYWC9040 H 04/12 WC-G-11 STIPULATION FOR COMPROMISE

SETTLEMENTWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

MontanaWC7745 E 09/13 ELECTRONIC PRIOR CLAIMS SYSTEM

ACCESS AGREEMENTWC7580 W 08/14 DLI-ERD-WCC041 FIRST REPORT OF INJURY OR

OCCUPATIONAL DISEASEWC9975 07/09 INSTRUCTIONS FOR FIRST REPORT OF

INJURYWC7777 B 06/14 MEDICAL PROVIDER BILLING REQUESTWC7792 D 07/11 DLI/ERD PS-DIC-LGL PETITION FOR SETTLEMENT (DISPUTED

INITIAL COMPENSABILITY)WC9774 C 10/11 DLI-ERD-WCC007 PETITION FOR SETTLEMENT (INJURY/

OCCUPATIONAL DISEASE) - MEDICALBENEFITS CLOSED BY SETTLEMET ONAN ACCEPTED CLAIM

WC9794 B 10/11 DLI-ERD-WCC002 PETITION FOR SETTLEMENT (INJURY/OCCUPATIONAL DISEASE) - MEDICALBENEFITS RESERVED

WC7977 D 10/11 ERD-WCCA-CA-PS016 PETITION FOR SETTLEMENT(PERMANENT TOTAL DISABILITY)INJURY/OCCUPATIONAL DISEASE(MEDICAL BENEFITS RESERVED)

WC7914 B 11/08 PETITION FOR SETTLEMENT INJURY/OCCUPATIONAL DISEASE

WC7695 B 04/14 DLI-ERD-WCC072 PETITION FOR WORKERS'COMPENSATION MEDIATIONCONFERENCE

WC9886 08/12 SAW/RTW ASSISTANCE OUTCOMEREPORTING FORM




WC8130 C 10/11 DLI-ERD-WCC005 SETTLEMENT/ADVANCE RECAP SHEETWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC9974 A 07/17 WORKERS' COMPENSATION BENEFITS

SUMMARY (7/1/16 TO 6/30/17)WC8443 G 02/10 ERD-922 WORKERS' COMPENSATION

SUBSEQUENT REPORTNebraska

WC9951 11/99 CHOOSING A DOCTOR FOR A WORK-RELATED INJURY (ENGLISH)

WC9952 11/99 CHOOSING A DOCTOR FOR A WORK-RELATED INJURY (SPANISH)

WC7662 B 03/13 NWCC FORM 50 EMPLOYEE'S CHOICE (SPANISH)WC8111 K 12/11 FORM 1 FIRST REPORT OF ALLEGED

OCCUPATIONAL INJURY OR ILLNESS(New) WC9854 B 03/17 IDR INFORMAL DISPUTE RESOLUTION

WC7682 A 04/08 NWCC FORM 67-2 NOTICE OF AGREEMENT TO USE ANAMED INDEPENDENT MEDICALEXAMINER

(New) WC7658 C 03/18 FORM 50 NOTICE OF EMPLOYEE’S RIGHT TOCHOOSE A DOCTOR

WC8689 06/95 NWCC FORM 12 RECORD OF COMPENSATIONINSURANCE

WC7676 B 04/08 NWCC FORM 63-1 REQUEST FOR INDEPENDENT MEDICALEXAMINER

WC9949 07/12 RIGHTS & OBLIGATIONS UNDER THENEBRASKA WORKERS' COMPENSATIONLAW (ENGLISH)

WC9950 07/12 RIGHTS & OBLIGATIONS UNDER THENEBRASKA WORKERS' COMPENSATIONLAW (SPANISH)

WC8117 G 06/06 NWCCFORM40606 SUBSEQUENT REPORTWC9855 C 02/17 VR-42B VOCATIONAL REHABILITATION

COUNSELOR APPOINTMENT REQUESTWC9855 D 08/17 VR-42B VOCATIONAL REHABILITATION

COUNSELOR APPOINTMENT REQUESTWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

NevadaWC9550 03/16 D-53 ALTERNATIVE CHOICE OF PHYSICIAN

OR CHIROPRACTOR AND REFERRAL TOA SPECIALIST

WC8664 B 04/04 D260404 APPLICATION FOR REIMBURSEMENT OFCLAIM RELATED TRAVEL EXPENSES

WC8963 07/99 D320799 AUTHORIZATION FOR ADDITIONALCHIROPRACTIC TREATMENT

WC8964 07/99 D330799 AUTHORIZATION REQUEST FORADDITIONAL PHYSICAL THERAPYTREATMENT

WC8658 A 07/99 D150799 ELECTION FOR NEVADA WORKERS'COMPENSATION COVERAGE FOR OUT-OF-STATE INJURY

WC8652 C 01/17 D-10A ELECTION OF METHOD OF PAYMENT OFCOMPENSATION

WC8653 A 07/99 D10B0799 ELECTION OF METHOD OF PAYMENTOF COMPENSATION FOR DISABILITYGREATER THAN 25%

WC9669 B 10/07 C-4 EMPLOYEE'S CLAIM FORCOMPENSATION/REPORT OF INITIALTREATMENT

WC8644 F 11/05 FORMC31105 EMPLOYER'S REPORT OF INDUSTRIALINJURY OR OCCUPATIONAL DISEASE

WC8649 B 10/10 D8




EMPLOYER'S WAGE VERIFICATIONFORM

WC8648 A 07/99 D70799 EXPLANATION OF WAGE CANCELATIONWC8659 A 07/99 D210799 FATALITY REPORTWC8692 E 07/17 D-38 INDEX OF CLAIMS SYSTEM CLAIM

REGISTRATION/UPDATE/REQUESTDOCUMENT

WC8647 A 07/99 D60799 INJURED EMPLOYEE'S REQUEST FORCOMPENSATION

WC8656 A 07/99 D130799 INJURED EMPLOYEE'S RIGHT TO REOPENA CLAIM WHICH HAS BEEN CLOSED

WC8965 A 12/03 D371203 INSURER'S SUBSEQUENT INJURYCHECKLIST

WC8665 A 07/99 D270799 INTEREST CALCULATION FORCOMPENSATION DUE

WC9178 07/99 D2910799 LUMP SUM REHABILITATIONAGREEMENT

WC8667 D 05/10 D-30 NOTICE OF CLAIM ACCEPTANCEWC8643 E 10/05 C11005 NOTICE OF INJURY OR OCCUPATIONAL

DISEASE (INCIDENT REPORT) PURSUANTTO NRS 616C.015

WC8668 E 10/10 D-31 NOTICE OF INTENTION TO CLOSE CLAIMWC9695 A 01/14 OD8 OCCUPATIONAL DISEASE CLAIM

REPORTWC8650 D 01/12 D-9A PERMANENT PARTIAL DISABILITY

AWARD CALCULATION WORK SHEETWC8651 D 01/12 D-9B PERMANENT PARTIAL DISABILITY

AWARD CALCULATION WORK SHEETFOR DISABILITY OVER 25% BODY BASIS

WC8657 A 07/99 D140799 PERMANENT TOTAL DISABILITYREPORT OF EMPLOYMENT

WC8966 07/99 D390799 PHYSICIAN'S AND CHIROPRACTOR'SPROGRESS REPORT CERTIFICATION OFDISABILITY

WC8654 A 07/99 D110799 REAFFIRMATION/RETRACTION OF LUMPSUM REQUEST

WC8666 A 07/99 D280799 REHABILITATION LUMP SUM REQUEST(New) WC8897 K 05/18 D-35 REQUEST FOR A ROTATING PHYSICIAN

OR CHIROPRACTORWC8669 B 12/07 D-36 REQUEST FOR ADDITIONAL MEDICAL

INFORMATION AND RELEASE FORMWC8655 E 12/07 D-12A REQUEST FOR HEARING--CONTESTED

CLAIMWC8662 B 06/06 D240606 REQUEST FOR REIMBURSEMENT OF

EXPENSES FOR TRAVEL AND LOSTWAGES

WC9813 04/10 SURVIVING SPOUSE REMARRIAGEREPORT - DEATH CLAIMS

WC8698 07/99 D460799 TEMPORARY PARTIAL DISABILITYCALCULATION WORKSHEET

WC8646 A 07/99 D50799 WAGE CALCULATION FORM FORCLAIMS AGENT'S USE

WC8733 10/95 IA21095 WC SUBSEQUENT REPORTNew Hampshire

WC8179 C 05/19 9WCA-2 APPLICATION FOR REIMBURSEMENTOF PAID ADJUSTED TOTALDISABILITYBENIFITS OR PAIDCOMBINED EARNINGS FOR ACTIVECASES OR 2ND INJURIES

WC9748 09/98 WCSIF10998 APPLICATION FOR USE OF SECONDINJURY FUND




WC8247 A 10/01 14WCA1001 AUTHORIZATION FOR COMPENSATIONFOR DEATH

WC8876 12/00 53WC1200 EMPLOYEE'S STATEMENT OFEMPLOYMENT STATUS

WC8195 K 12/14 8WC EMPLOYER'S FIRST REPORT OFOCCUPATIONAL INJURY OR DISEASE (3PART CARBON SET—ONE COPY EACHFOR LABOR DEPARTMENT, INSURANCECLAIMS OFFICE AND EMPLOYER)

WC8200 E 03/14 13WCA EMPLOYER'S SUPPLEMENTAL REPORTOF INJURY (3 PART SET—1 COPY EACHFOR EMPLOYER, INSURANCE CLAIMSOFFICE AND LABOR DEPARTMENT)

WC8198 B 10/99 15WCA1099 LUMP SUM SETTLEMENT AGREEMENTWC7717 F 09/15 9WCA1 MEMO OF DENIAL OF WORKERS'

COMPENSATION BENEFITSWC8084 H 06/94 9WCA0694 MEMO OF PAYMENT OF DISABILITY

COMPENSATION (3 PART CARBONIZEDSET, ONE COPY EACH—DEPT. OF LABOR,EMPLOYEE, INS. CARRIER)

WC8197 C 10/98 10WCA1098 MEMO OF PERMANENT IMPAIRMENTAWARD

WC7982 H 07/14 8AWCA NOTICE OF ACCIDENTAL INJURY OROCCUPATIONAL DISEASE 8AWCA

WC8877 12/00 53A1200 NOTICE OF INTENTION TOSUSPEND PAYMENT OF WORKERS'COMPENSATION BENEFITS

WC8176 A 06/15 WC-3PR-1 RELEASE AND SETTLEMENT OF CLAIMWC8064 A 07/89 74WCA0789 REPORT OF EXTENDED DISABILITYWC8710 C 05/13 WCSIF-2 REQUEST FOR REIMBURSEMENT FROM

THE SECOND INJURY FUNDWC8711 A 05/13 WCSIF2A SCHEDULE OF REIMBURSABLE

PAYMENTSWC9749 A 03/10 WCSIF1A SECOND INJURY FUND AFFIDAVIT OF

EMPLOYEE KNOWLEDGEWC9750 12/96 WCSIF1B1296 SECOND INJURY FUND CERTIFICATION

BY PHYSICIAN (NEW HAMPSHIRE)WC8184 B 10/17 76WCA1 SUPPLEMENTAL WAGE SCHEDULEWC8086 G 09/15 76WCA WAGE SCHEDULE (2 PART SET-ONE

COPY EACH FOR LABOR DEPARTMENTAND INSURANCE CLAIMS OFFICE)

WC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC7681 06/94 75WCA1 WORKER'S COMPENSATION MEDICAL

FORMWC8703 09/15 23-B WC WORKER'S COMPENSATTION TASK

ANALYSISNew Jersey

WC9653 E 03/13 WC-377I ADDENDUM TO ORDER FOR TOTALDISABILITY

WC9650 09/05 WC36610905 AFFIDAVIT OF DEPENDENT ORDEPENDENT(S) REPRESENTATIVE INSUPPORT OF SETTLEMENT UNDERN.J.S.A. 34:15-20

WC9405 B 06/15 WC-369 ANSWER TO APPLICATION FOR REVIEWOR MODIFICATION OF FORMAL AWARD

WC9407 D 06/07 WC170I0607 ANSWERING STATEMENT TO MOTIONFOR TEMPORARY AND MEDICALBENEFITS

WC9599 B 02/06 WCCF660206 APPLICATION FOR INFORMAL HEARINGWC9416 C 08/15 WC368 APPLICATION FOR REVIEW OR

MODIFICATION OF FORMAL AWARD




WC9417 D 08/15 WC-366 DEPENDENCY CLAIM PETITIONWC8818 F 08/15 WC-365 EMPLOYEE CLAIM PETITIONWC9415 B 09/14 WC-365.1 EMPLOYEE'S CLAIM PETITION

SUPPLEMENTAL PAGEWC9402 D 07/07 WC101I0707 NOTICE OF MOTION FOR TEMPORARY

AND/OR MEDICAL BENEFITSWC9408 06/03 WC23 OCCUPATIONAL INTERROGATORIES

(STANDARD RESPONDENT'S)WC9412 F 08/15 WC-100 ORDER (JUDGEMENT, APPROVING

SETTLEMENT, DISMISSAL,DISCONTINUANCE)

WC9414 F 04/13 WC(DO)370 ORDER APPROVING SETTLEMENT WITHDISMISSAL N.J.S.A. 34:15-20

WC9711 D 07/13 WC-100 ORDER FOR DISMISSALWC9649 G 03/13 WC-374I ORDER FOR TOTAL DISABILITYWC9651 F 03/13 WC-376I ORDER FOR TOTAL DISABILITY WITH

SECOND INJURY FUNDWC9652 G 03/13 WC-375I ORDER TOTAL DISABILITY W/SOCIAL

SECURITY OFFSETWC8724 D 06/14 WC147 REQUEST FOR RECORDS INSPECTIONWC9411 A 06/04 WC1240604 REQUEST FOR SOCIAL SECURITY

INFORMATIONWC9404 C 05/15 WCF367 RESPONDENT'S ANSWER TO CLAIM

PETITIONWC9406 B 07/04 WC1710704 RESPONDENT'S ANSWER TO

DEPENDENCY CLAIM PETITIONWC9403 06/03 WC22 STANDARD PETITIONER'S

OCCUPATIONAL INTERROGATORYFORM

WC9409 A 08/04 WC100804 SUBSTITUTION OF ATTORNEYWC7586 B 10/97 USRASWGFRMNJ1097 UNIT STATISTICAL REPORTWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

New MexicoWC8782 C 10/15 FORM LETTER TO HEALTH CARE

PROVIDERWC8770 A 01/18 NOTICE OF ACCEPTANCE OR REJECTION

OF RECOMMENDED RESOLUTIONWC7592 B 05/00 E6.2 NOTICE OF BENEFIT PAYMENTWC8781 F 10/17 PETITION FOR LUMP SUM PAYMENTWC8775 A 10/17 RESPONSE (TO WORKER'S COMPLAINT)WC8776 C 01/18 SUMMONS FOR APPLICATION TO

WORKERS’ COMPENSATION JUDGEWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC8778 G 02/18 WORKERS' COMPENSATION COMPLAINTWC9658 A 03/18 WORKER'S RESPONSE TO APPLICATION

TO WORKERS' COMPENSATION JUDGENew York

WC9681 09/05 25A0905 AFFIDAVITWC9398 P 06/16 AFF-1 AFFIDAVIT FOR DEATH BENEFITSWC9685 A 08/06 WTCAFFDP0806 AFFIDAVIT FOR DEATH BENEFITS

WHERE THERE IS NO SURVIVINGSPOUSE: FOR DOMESTIC PARTNERS

WC9036 E 01/11 ADR2 ALTERNATIVE DISPUTE RESOLUTIONPROGRAM FINAL DISPOSITION OF CLAIM

WC9788 D 10/15 C-4 AMR ANCILLARY MEDICAL REPORTWC8896 J 09/17 OC-400.1 APPLICATION FOR A FEE BY

CLAIMANT'S ATTORNEY ORREPRESENTATIVE

WC9082 A 10/17 DB-85 APPLICATION FOR ACCEPTANCE OFINSURANCE FORM UNDER SECTION360.1(B)(1) NYCRR




WC9380 F 01/11 C21 APPLICATION FOR AN ADVANCEON PERIODIC PAYMENTS OFCOMPENSATION

WC7728 N 01/11 C22 APPLICATION FOR APPROVAL OF NON-SCHEDULE ADJUSTMENT

WC7503 Q 01/18 RB-89 APPLICATION FOR BOARD REVIEWWC9185 D 01/11 C-25 APPLICATION FOR REOPENING OF

CLAIM, MORE THAN SEVEN YEARSAFTER ACCIDENT

WC8940 05/01 ATTACHMENT TO FORMWC9758 H 04/18 C-4 AUTH ATTENDING DOCTOR REQUEST FOR

AUTHORIZATION AND CARRIER'SRESPONSE (NY)

WC9844 D 12/14 MG-2 ATTENDING DOCTOR'S REQUESTFOR APPROVAL OF VARIANCE ANDCARRIER'S RESPONSE

WC9116 F 01/11 MD1 ATTENDING DOCTOR'S REQUESTFOR MEDICAL AUTHORIZATIONDETERMINATION

WC9842 D 12/14 MG-1 ATTENDING DOCTOR'S REQUEST FOROPTIONAL PRIOR APPROVAL ANDCARRIER'S/EMPLOYER'S RESPONSE

WC8361 S 10/15 C-5 ATTENDING OPTHALMOLOGIST'SREPORT

WC8999 H 10/15 PS-4 ATTENDING PSYCHOLOGIST'S REPORTWC9776 A 06/13 OC-400.5 ATTORNEY/REPRESENTATIVE'S

CERTIFICATION OF FORM C-3 OR NOTICEOF CONTROVERSY

UG214 B 02/11 DOH-2557 AUTHORIZATION FOR RELEASEOF HEALTH INFORMATION ANDCONFIDENTIAL HIV-RELATEDINFORMATION

UG215 A 02/11 DOH-2557ES AUTHORIZATION FOR RELEASEOF HEALTH INFORMATION ANDCONFIDENTIAL HIV-RELATEDINFORMATION (SP)

WC9640 A 09/05 DD20905 BIANNUAL RECERTIFICATION TOENTITLEMENT TO BENEFITS

WC9118 A 08/03 MD40803 CARRIER SELF/INSURED EMPLOYER'SOBJECTION TO BOARD'S AFFIRMANCEOF ORDER OF THE CHAIR AUTHORIZINGSPECIAL SERVICES

WC9081 02/00 DB8400200 CARRIER'S DESIGNATION OFAUTHORIZED REPRESENTATIVES

WC7501 F2 08/05 FORMR0805 CARRIER'S REPORT ON REHABILITATIONWC9704 10/06 VFVAW101006 CARRIER'S REQUEST FOR BENEFIT

INCREASE REIMBURSEMENT UNDERSECTION 51 VOLUNTEER FIREFIGHTERS'& VOLUNTEER AMBULANCE WORKERS'BENEFIT LAWS

(New) WC9983 A 05/18 C-251N CARRIER'S REQUEST FOR INITIALREIMBURSEMENT OF INDEMNITYPAYMENTS UNDER WCL SECTION 15(8)(EXCEL SPREADSHEET FORMAT ONLY)

(New) WC1011 05/18 C-251.6 CARRIER'S REQUEST FORRECONSIDERATION OF REDUCTIONUNDER WCL SECTION 14(6) OR SECTION15(8)

WC8310 D 10/16 C251A CARRIER'S REQUEST FORREIMBURSEMENT OF INDEMNITY




PAYMENTS UNDER WCL SECTION 15(8)(EXCEL SPREADSHEET FORMAT ONLY)

WC8311 D 05/18 WC-251.1 CARRIER'S REQUEST FORREIMBURSEMENT OF MEDICALEXPENSES UNDER SECTION 15-8

WC9117 F 01/11 MD3 CARRIER'S/SELF-INSURED EMPLOYER'SOBJECTION TO ATTENDINGDOCTOR'S REQUEST FOR MEDICALAUTHORIZATION DETERMINATION

WC9003 E 01/11 C-121 CLAIM FOR COMPENSATION ANDNOTICE OF COMMENCEMENT OF THIRDPARTY ACTION

WC7923 P 01/11 C62 CLAIM FOR COMPENSATION IN A DEATHCASE

WC8708 A 12/05 DB4701205 CLAIM FOR REIMBURSEMENT OFBENEFITS PAID UNDER THE NEW YORKDISABILITY BENEFITS LAW

WC9004 E 01/11 VAW62 CLAIM FOR VOLUNTEER AMBULANCEWORKERS'BENEFITS IN A DEATH CASE

WC9005 E 01/11 VF62 CLAIM FOR VOLUNTEER FIREFIGHTERS'BENEFIT IN A DEATH CASE

WC9790 C 08/16 CLAIMANT INFORMATION PACKET(INFORMATION SHEET ONLY).

WC9474 12/03 HIPAA11203 CLAIMANT'S AUTHORIZATION TODISCLOSE HEALTH INFORMATION

WC8894 M 12/17 OC-110A CLAIMANT'S AUTHORIZATION TODISCLOSE WORKERS' COMPENSATIONRECORDS

WC9494 C 01/11 OC110AS CLAIMANT'S AUTHORIZATION TODISCLOSURE WORKERS' COMPENSATIONRECORDS (PURSUANT TO WORKERS'COMPENSATION LAW SECTION 110-A)(SPANISH)

(New) WC8887 K 05/18 IME-5 CLAIMANT'S NOTICE OF INDEPENDENTMEDICAL EXAMINATION UNDERSECTION 137 WCL

WC9997 07/17 C-258.1 CLAIMANT'S RECORD OF INDEPENDENTJOB SEARCH EFFORTS

WC9996 07/17 C-258 CLAIMANT'S RECORD OF JOB SEARCHEFFORTS/CONTACTS

WC8817 B 09/10 C257 CLAIMANT'S RECORD OF MEDICAL ANDTRAVEL EXPENSES

WC9208 G 01/11 RFA-1W CLAIMANT'S REQUEST FOR FURTHERACTION

WC9072 C 09/08 C410908 CONTINUATION TO CARRIER/EMPLOYERBILLING PORTION OF FORMS C-4, C-5,PS-4 OR OT/PT-4

WC9843 B 12/14 MG-1.1 CONTINUATION TO FORM MG-1,ATTENDING DOCTOR'S REQUEST FOROPTIONAL PRIOR APPROVAL

WC9845 B 12/14 MG-2.1 CONTINUATION TO FORM MG-2,ATTENDING DOCTOR'S REQUEST FORAPPROVAL OF VARIANCE

WC9699 A 07/07 WTC160707 COVER SHEET: LIST OF ITEMIZEDMEDICAL BILLS IN CONTROVERTEDWORLD TRADE CENTER CASE

WC9639 C 05/15 DD1 DIRECT DEPOSIT AND DEBIT CARDAUTHORIZATION FORM

WC9083 B 01/11 DC120 DISCHARGE OR DISCRIMINATIONCOMPLAINT

WC7559 J 10/15 C-4 DOCTOR'S INITIAL REPORT




WC9756 E 10/15 C-4.2 DOCTOR'S PROGRESS REPORT (NY)(New) WC9757 F 05/18 C-4.3 DOCTOR'S REPORT OF MMI/PERMANENT

IMPAIRMENTWC9755 B 01/11 C-3S EMPLOYEE CLAIM [SPANISH] (NY)WC8233 T 01/11 C-3 EMPLOYEE'S CLAIM FOR

COMPENSATIONWC9074 A 08/03 DB1350803 EMPLOYER'S APPLICATION FOR

VOLUNTARY COVERAGE FOR CLASSOF EMPLOYEES FOR WHOM DISABILITYBENEFITS ARE NOT REQUIRED BY LAW(EMPLOYEE CONT NOT REQ)

WC9075 A 08/03 DB1360803 EMPLOYER'S APPLICATION FORVOLUNTARY COVERAGE FOR CLASSOF EMPLOYEES FOR WHOM DISABILITYBENEFITS ARE NOT REQUIRED BY LAW(EMPLOYEE CONT REQ)

WC9922 A 01/14 C-2F EMPLOYER'S FIRST REPORT OF WORK-RELATED INJURY/ILLNESS

WC7591 Z 06/17 C-11 EMPLOYER'S REPORT OF INJUREDEMPLOYEE'S CHANGE IN EMPLOYMENTSTATUS RESULTING FROM INJURY

WC9946 08/05 C-107 EMPLOYER'S REQUEST FORREIMBURSEMENT

WC8099 U 06/17 C-240 EMPLOYER'S STATEMENT OF WAGEEARNINGS (PRECEDING THE DATE OFACCIDENT)

WC7579 D 07/16 HIMP-1 HEALTH INSURERS REQUEST FORREIMBURSEMENT

WC8893 C 04/05 MRIME10405 HEALTH PROVIDER'S APPLICATION FORAUTHORIZATION UNDER THE WORKERS'COMPENSATION LAW

WC7953 E 08/14 HP-1 HEALTH PROVIDER'S REQUEST FORDECISION ON UNPAID MEDICAL BILL(S)

WC9754 B 12/09 C-3.3 LIMITED RELEASE OF HEALTH INFO (NY)(New) WC1012 10/12 C-3.3S LIMITED RELEASE OF HEALTH

INFORMATION (SPANISH)WC9876 01/12 VDF-1 LOSS OF WAGE EARNING CAPACITY -

VOCATIONAL DATA FORMWC9773 04/09 LUMP SUM - SECTION 32 SETTLEMENT

REQUESTWC9001 D 01/11 C27 MEDICAL PROOF OF CHANGE

IN CONDITION IN SUPPORT OFAPPLICATION FOR REOPENING OFCLAIM FOR WORKERS' COMPENSATION,VOLUNTEER FIRE FIGHTERS' ORVOLUNTEER AMBULANCE WORKERS'BENEFITS

WC8784 09/99 MEDICAL REIMBURSEMENTS (15-8DETAIL SHEET)

WC8202 R 09/17 DB-4500917 NOTICE AND PROOF OF CLAIM FORDISABILITY BENEFITS

WC9077 C 02/04 DB3000204 NOTICE AND PROOF OF CLAIM FORDISABILITY BENEFITS BY EMPLOYEDCLAIMANT

WC8186 K2 03/07 C2500307 NOTICE OF CLAIM FORREIMBURSEMENT

WC9079 03/99 DB4550399 NOTICE OF DISABILITY BENEFITSPAYMENT

WC9084 B 01/18 OC406 NOTICE OF RETAINER ANDAPPEARANCE ON BEHALF OF EMPLOYER

WC8895 H 01/18 OC-400




NOTICE OF RETAINER ANDAPPEARANCE/SUBSTITION/ADDITIONALATTORNEY

WC8628 B 03/04 C310304 NOTICE OF RIGHT TO SELECT AWORKERS' COMPENSATION BOARDAUTHORIZED HEALTH CARE PROVIDER

WC8442 D2 03/99 DB4510399 NOTICE OF TOTAL OR PARTIALWC7979 C 12/14 C-8.1 NOTICE OF TRATMENTS ISSUES/

DISPUTED BILL ISSUESWC9880 03/12 DT-1 NOTICE THAT CLAIMANT MUST

ARRANGE FOR DIAGNOSTIC TESTS &EXAMINATIONS THROUGH A NETWORKPROVIDER

WC9401 B 01/07 A90107 NOTICE THAT YOU MAY BERESPONSIBLE FOR MEDICAL COSTS INTHE EVENT OF FAILURE TO PROSECUTE,OR IF COMPENSATION CLAIM ISDISALLOWED, OR IF AGREEMENTPURSUANT TO WCL 32 IS APPROVED(ENGLISH/SPANISH)

WC9759 B 01/11 C-8.4 NOTICE TO HEALTH CARE PROVIDERAND INJURED WORKER OF A CARRIER'SREFUSAL TO PAY ALL (OR A PORTIONOF) A MEDICAL BILL DUE TOVALUATION OBJECTION(S)

WC9086 08/97 VF10897 NOTICE TO LIABLE POLITICALSUBDIVISION OF VOLUNTEERFIREFIGHTER'S INJURY OR DEATH

WC9085 08/97 VAW10897 NOTICE TO LIABLE POLITICALSUBDIVISION OR UNAFFILIATEDAMBULANCE SERVICE OF VOLUNTEERAMBULANCE WORKERS' INJURY ORDEATH

WC9000 H 10/15 OT/PT-4 OCCUPATIONAL/PHYSICAL THERAPIST'SREPORT

(New) WC8891 J 05/18 IME4 PRACTITIONEER'S REPORT OFINDEPENDENT MEDICAL EXAMINATION

WC9216 C 01/11 FCE-4 PRACTITIONER'S REPORT OFFUNCTIONAL CAPACITY EVALUATION

WC8890 F 07/14 IME-3 PRACTITIONER'S REPORT OF REQUESTFOR INFORMATION/RESPONSE TOREQUEST REGUARDING INDEPENDENTMEDICAL EXAMINATION

WC9007 D 01/11 C-65 PROOF OF BURIAL AND FUNERALEXPENCES-BY UNDERTAKER

WC9006 E 01/11 C64 PROOF OF DEATH (BY PHYSICIAN LASTIN ATTENDANCE ON DECEASED)

WC7505 Q 01/18 RB-89.1 REBUTTAL OF APPLICATION FOR BOARDREVIEW

WC9181 D 01/12 C-72.1 RECORD OF PERCENTAGE HEARINGLOSS

WC9698 G 09/16 WTC-12 REGISTRATION OF PARTICIPATIONIN WORLD TRADE CENTER RESCUE,RECOVERY AND/OR CLEAN-UPOPERATIONS

WC9035 E 01/11 ADR1 REPORT OF WORK-RELATED INJURY OROCCUPATIONAL DISEASE

WC9209 K 10/16 RFA-2 REQUEST FOR FURTHER ACTION BYCARRIER/EMPLOYER

WC8082 C2 11/96 C10541196 REVOCATION OF ELECT OFWC8889 M 02/16 C-32.1




SECTION 32 WAIVER AGREEMENT:CLAIMANT RELEASE

WC9965 02/16 C-32-I SETTLEMENT AGREEMENT - SECTION32 WCL INDEMNITY ONLY SETTLEMENTAGREEMENT

WC8892 B 07/14 IME7 STATEMENT OF REGISTRATION -SECTION 13-N WCL

WC7507 Y 11/17 DB-271S STATEMENT OF RIGHTS - DISABILITYBENEFITS LAW

WC8040 Z 09/16 C-430S STATEMENT OF RIGHTS (ENGLISH/SPANISH)

WC8530 10/97 C300341097 STATEMENT OF UNRESOLVED ISSUESSPECIAL PART FOR EXPEDITEDHEARINGS

WC7965 T 03/14 PH-16.2 STATEMENT ON SPECIFIC ISSUES INDISPUTE FOR CONTROVERTED ANDEXPEDITED CASES

WC8494 A 10/16 C-300.5 STIPULATIONWC9002 D 01/11 VAW-3 VOLUNTEER AMBULANCE WORKERS'

CLAIM FOR BENEFITSWC8709 J 01/11 VF3 VOLUNTEER FIREFIGHTERS' CLAIM FOR

BENEFITSWC9718 C 01/11 VF/VAW-11C VOLUNTEER'S NOTIFICATION OF

EXECUTIVE OFFICER OF FIRE/AMBULANCE COMPANY OFSIGNIFICANT RISK OF TRANSMISSION OFHIV

WC8493 J 02/16 C-32 WAIVER AGREEMENT - SECTION 32 WCLWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC8020 D 04/05 HP40405 WITHDRAWAL OF REQUEST FOR

ARBITRATIONNorth Carolina

WC9252 03/03 FORM87A0303 AFFIDAVIT OF ACCRUED ARREARAGESG.S. 97-87(D)

WC8350 G 02/17 FORM 30 AGREEMENT FOR COMPENSATION FORDEATH

WC8256 M 02/17 FORM 26 AGREEMENT FOR COMPENSATION FORDISABILITY

WC8325 N 02/17 FORM 21 AGREEMENT FOR COMPENSATION FORDISABILITY

WC9561 A 03/07 FORMA210307 AGREEMENT FOR COMPENSATION FORDISABILITY (SPANISH)

WC8351 D 02/01 FORM 26D AGREEMENT FOR PAYMENT OF UNPAIDCOMPENSATION IN UNRELATED DEATHCASES (G.S. 97-37)

WC8245 J 02/17 FORM 51 ANNUAL CONSOLIDATED FISCALREPORT OF "MEDICAL ONLY" AND"LOST TIME" CASES

WC9089 C 10/17 FORM 42 APPLICATION FOR APPOINTMENT OFGUARDIAN AD LITEM

WC7749 G 02/17 FORM 31 APPLICATION FOR LUMP SUM AWARDWC8347 K 03/18 FORM 44 APPLICATION FOR REVIEWWC8307 R 02/18 FORM 24 APPLICATION TO TERMINATE OR

SUSPEND PAYMENT OF COMPENSATION(G.S. 97-18.1)

WC8346 B 08/14 T-44 APPLICATON FOR REVIEWWC9088 D 01/04 FORM25C AUTHORIZATION FOR REHABILITATION

PROFESSIONAL TO OBTAIN MEDICALRECORDS OF CURRENT TREATMENT

WC9527 B 04/06 FORMA25C AUTHORIZATION FOR REHABILITATIONPROFESSIONAL TO OBTAIN MEDICAL




RECORDS OF CURRENT TREATMENT(SPANISH)

WC8930 E 02/17 FORM 30D AWARD APPROVING AGREEMENT FORCOMPENSATION FOR DEATH

WC9553 A 10/05 FORM25A1005 CERTIFICATION OF MATERIAL MEDICALAND VOCATIONAL RECORDS

WC9795 09/09 CERTIFICATION OF PAYMENT OFPROCESSING FEE FOR COMPROMISESETTLEMENT AGREEMENTS

WC7747 F 10/17 FORM 18B CLAIM BY EMPLOYEE,REPRESENTATIVE, OR DEPENDENT FORBENEFITS FOR LUNG DISEASE

WC9096 B 10/17 FORM T1 CLAIM FOR DAMAGES UNDER TORTCLAIMS ACT

WC9852 01/11 CLAIM FOR DEATH BENEFITSWC8240 H 02/17 FORM 61 DENIAL OF WORKERS' COMPENSATION

CLAIMWC9087 A 03/03 DENTAL CLAIM FORMWC9092 D 10/17 MSC4 DESIGNATION OF MEDIATORWC8353 F 10/17 FORM 18M EMPLOYEE’S APPLICATION FOR

ADDITIONAL MEDICAL COMPENSATIONWC8707 G 10/17 FORM 28U EMPLOYEE'S REQUEST THAT

COMPENSATION BE REINSTATED AFTERUNSUCCESSFUL TRIAL RETURN TOWORK

WC9752 E 02/17 FORM-26A EMPLOYER ADM OF EMPLOYEE RIGHT(NC)

WC8241 J 02/17 FORM 60 EMPLOYER’S ADMISSION OFEMPLOYEE’S RIGHT TO COMPENSATION

WC8301 S 10/17 FORM 19 EMPLOYER'S REPORT OF EMPLOYEE'SINJURY OR OCCUPATIONAL DISEASE TOTHE INDUSTRIAL COMMISSION

WC7882 J 05/17 FORM 25R EVALUATION FOR PERMANENTIMPAIRMENT

WC7879 E 10/17 FORM 25P ITEMIZED STATEMENT OF CHARGES FORDRUGS

WC7748 W 12/17 FORM 25T ITEMIZED STATEMENT OF CHARGES FORTRAVEL

WC9094 G 10/17 MSC6 MEDIATOR'S DECLARATION OFINTEREST AND QUALIFICATIONS

WC7746 K 03/18 FORM 18 NOTICE OF ACCIDENT TO EMPLOYERAND CLAIM OF EMPLOYEE,REPRESENTATIVE, OR DEPENDENT

WC9520 B 08/08 FORMA18 NOTICE OF ACCIDENT TO EMPLOYERAND CLAIM OF EMPLOYEE,REPRESENTATIVE, OR DEPENDENT(SPANISH)

WC9968 A 02/17 FORM 30A NOTICE OF AWARDWC8237 H 02/17 FORM 62 NOTICE OF REINSTATEMENT OR

MODIFICATION OF COMPENSATIONWC8249 F 02/17 FORM 28T NOTICE OF TERMINATION OF

COMPENSATION BY REASON OF TRAILRETURN TO WORK (G.S. 97-18.1(B) ANDG.S. 97-32.1

WC8238 J 02/17 FORM 63 NOTICE TO EMPLOYEE OF PAYMENT OFCOMPENSATION WITHOUT PREJUDICEOR PAYMENT OF MEDICAL BENEFITSONLY WITHOUT PREJUDICE

WC9502 04/04 NOTICE TO EMPLOYEE RECEIVINGWORKERS' COMPENSATION BENEFITS

WC8352 J 02/16 FORM 25N




NOTICE TO THE COMMISSION OFASSIGNMENT OF REHABILITATIONPROFESSIONAL

WC9091 E 10/17 MSC2 PETITION FOR ORDER REFERRINGCASE TO MEDIATED SETTLEMENTCONFERENCE

WC9090 11/01 PETITION TO APPEAR AS AN INDIGENTPERSON

WC9098 B 10/17 PETITION TO SUE AS AN INDIGENTPERSON

WC9097 A 05/02 T30502 RELEASE OF TORT CLAIM (G.S. 143-291ET SEQ.)

WC8931 B 10/17 FORM 90 REPORT OF EARNINGSWC8327 M 02/17 FORM28B REPORT OF EMPLOYER OR CARRIER/

ADMINISTRATOR OF COMPENSATIONAND MEDICAL COMPENSATION PAIDAND NOTICE OF RIGHT TO ADDITIONALMEDICAL COMPENSATION

WC9473 C 02/17 FORM28C REPORT OF EMPLOYER OR CARRIER/ADMINISTRATOR OF COMPENSATIONAND MEDICAL COMPENSATIONPAID PURSUANT TO A COMPROMISESETTLEMENT AGREEMENT

WC9095 D 10/17 MSC7 REPORT OF EVALUATORWC9093 E 10/17 MSC5 REPORT OF MEDIATORWC8349 H 03/18 FORM 33 REQUEST THAT CLAIM BE ASSIGNED

FOR HEARINGWC9560 A 09/04 FORMA33 REQUEST THAT CLAIM BE ASSIGNED

FOR HEARING (SPANISH)WC8348 J 03/18 FORM 33R RESPONSE TO REQUEST THAT CLAIM BE

ASSIGNED FOR HEARINGWC8312 K 02/16 FORM 28 RETURN TO WORK REPORTWC9254 B 10/17 FORM 87S STATEMENT OF ACCRUED ARREARAGES

G.S. 97-87(C)(1)WC7841 G 02/17 FORM 22 STATEMENT OF DAYS WORKED AND

EARNINGS OF INJURED EMPLOYEEWC8314 H 02/17 FORM 29 SUPPLEMENTAL REPORT FOR FATAL

ACCIDENTSWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC9648 12/05 WORKERS' COMPENSATION MEDICAL

STATUS QUESTIONNAIREWC9853 D 02/16 WORKERS' COMPENSATION NURSES

SECTION REFERRAL FORMNorth Dakota

WC9603 A 11/17 SFN 2828 FIRST REPORT OF INJURYWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

OhioWC9547 10/97 SI431097 ACKNOWLEDGMENT OF THE SELF

INSURED JOINT SETTLEMENTAGREEMENT AND RELEASE

WC9501 B 06/12 IC-GC1 AGREEMENT AS TO COMPENSATION FORPERMANENT PARTIAL DISABILITY

WC9679 02/99 OD58220299 APPLICATION FOR ADJUSTMENT OFCLAIM IN CASE OF DEATH DUE TOOCCUPATIONAL DISEASE

WC9546 A 09/10 C-92 APPLICATION FOR DETERMINATION OFPERCENTAGE OF PERMANENT PARTIALDISABILITY

WC9491 A 08/06 IC880806 APPLICATION FOR PERMANENTPARTIAL RECONSIDERATION

(New) WC1013 09/13 C-101-ES




AUTHORIZATION TO RELEASE MEDICALINFORMATION

WC9488 B 09/13 C-101 AUTHORIZATION TO RELEASE MEDICALINFORMATION

WC9461 K 06/14 FROI-1 FIRST REPORT OF AN INJURY,OCCUPATIONAL DISEASE OR DEATH

WC9678 C 05/14 C140 INITIAL APPLICATION FOR WAGE LOSSCOMPENSATION

WC9545 E 11/14 C-60 INJURED WORKER STATEMENT FORREIMBURSEMENT OF TRAVEL EXPENSE

WC9489 C 09/08 C86 MOTIONWC9485 D 06/11 IC12 NOTICE OF APPEALWC9686 09/99 C230999 NOTICE TO CHANGE PHYSICIAN OF

RECORDWC9487 B 11/07 IC167T OBJECTION TO TENTATIVE ORDERWC9674 C 03/16 RH1 REHABILITATION AGREEMENTWC9498 C 05/14 IC-51 REQUEST FOR CONTINUANCEWC9677 D 06/12 C-84 REQUEST FOR TEMPORARY TOTAL

COMPENSATIONWC9486 A 01/05 SI420105 SELF INSURED JOINT SETTLEMENT

AGREEMENT AND RELEASEWC9490 A 08/09 C174 SELF INSURED SEMI-ANNUAL REPORT

OF CLAIM PAYMENTSWC9680 04/06 SELF INSURERS AGREEMENTWC9676 D 05/17 C-240 SETTLEMENT AGREEMENT AND

APPLICATION FOR APPROVAL OFSETTLEMENT AGREEMENT

WC9675 B 05/15 C-18 WAGE AGREEMENTWC9458 F 09/15 WAGES-EMP WAGE STATEMENTWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

OklahomaWC8069 N 04/18 CC-FORM 10 ANSWER AND NOTICE OF CONTESTED

ISSUES(New) WC9395 E 04/18 CC-FORM 93 APPLICATION AND ORDER FOR LEAVE

TO WITHDRAW AS ATTORNEY OFRECORD

WC9055 E 02/14 CERTIFICATE CERTIFICATE TO JOINT PETITION(New) WC9052 J 04/18 CC-FORM-100 CLAIMANT’S APPLICATION AND ORDER

FOR DISMISSALWC9053 H 04/18 CC-FORM A CLAIMANT’S APPLICATION FOR

CHANGE OF PHYSICIAN AND REQUESTFOR HEARING

WC1543 P 04/18 CC-FORM 3A CLAIMANT’S FIRST NOTICE OF DEATHAND CLAIM FOR COMPENSATION

WC9054 G 03/17 COPY REQUEST FORMWC9048 G 09/15 CC-FORM 7 DESIGNATION OF SERVICE AGENTWC8061 P 04/18 CC-FORM 3 EMPLOYEE’S FIRST NOTICE OF CLAIM

FOR COMPENSATIONWC1545 P 04/18 CC-FORM 3B EMPLOYEE’S FIRST NOTICE OF

OCCUPATIONAL DISEASE AND CLAIMFOR COMPENSATION

(New) WC1548 K 04/18 FORM 3F EMPLOYEE’S NOTICE OF CLAIM FORBENEFITS FROM THE MULTIPLE INJURYTRUST FUND

WC9938 B 04/18 2A EXTENSION EMPLOYER’S APPLICATION ANDAUTHORIZATION FOR EXTENSION OFTIME TO FILE CC-FORM-2A

WC8101 W 04/18 CC-FORM-2 EMPLOYER’S FIRST NOTICE OF INJURYWC9931 A 06/15 FORM 2 EMPLOYER’S FIRST NOTICE OF INJURY

(ONLY FOR CLAIMS EXISTING PRIOR TO2/1/2014)




WC9929 D 04/18 2A EXTENSION EMPLOYER’S INTENT TO ACCEPT ORCONTROVERT CLAIM

WC1541 T 04/18 CS-JOINT-PETITION JOINT PETITION SETTLEMENTWC9243 C 02/16 MEDIATION REQUEST FORMWC9856 E 02/16 CC-FORM-A ORDER ORDER FOR CHANGE OF TREATING

PHYSICIAN(New) WC9397 F 04/18 CC-FORM 99 PAUPER’S AFFIDAVIT

WC9049 F 02/16 CC-FORM 17 PHYSICIAN DISCLOSURE STATEMENTWC8213 M 04/18 CC-FORM 5 PHYSICIAN’S REPORT ON RELEASE AND

RESTRICTIONSWC9051 F 04/18 CC-FORM-20 PROOF OF LOSS (DEATH CLAIM)WC8109 R 04/18 MFDR FORM 19 PROVIDER REQUEST FOR MEDICAL FEE

DISPUTE RESOLUTION(New) WC8122 P 04/18 CC-FORM-4 REPORT OF COMPENSATION PAID/

SUSPENSION OF PAYMENTSWC1549 Q 04/18 CC-FORM 9 REQUEST FOR HEARINGWC1540 P 04/18 CC-FORM 13 REQUEST FOR PREHEARING

CONFERENCEWC8072 M 04/18 CC-FORM-10M RESPONSE TO PROVIDER REQUEST FOR

MEDICAL FEE DISPUTE RESOLUTIONWC9932 C 04/18 CC-FORM-V VERIFICATION OF PERMANENT TOTAL

DISABILITYOregon

WC8886 F 01/18 440-3283 A GUIDE FOR WORKERS RECENTLYHURT ON THE JOB

WC9953 07/10 440-3283R A GUIDE FOR WORKERS' RECENTLYHURT ON THE JOB (RUSSIAN)

WC9259 E 01/18 440-3283S A GUIDE FOR WORKERS RECENTLYHURT ON THE JOB (SPANISH)

WC9954 07/10 440-3283V A GUIDE FOR WORKERS' RECENTLYHURT ON THE JOB (VIETNAMESE)

WC8878 A 01/08 44011740108 APPLICATION FOR APPROVAL OF LUMP-SUM PAYMENT OF AWARD

WC7810 E 05/15 440-1644C CORRECTING NOTICE OF CLOSUREWC9690 B 10/15 440-3228 ELECTIVE SURGERY NOTIFICATIONWC9625 H 01/17 440-2360 EMPLOYER-AT-INJURY PROGRAM (EAIP)

REIMBURSEMENT REQUEST FORMWC8470 D 01/10 440-1503 INSURER NOTICE OF CLOSURE

SUMMARYWC9475 D 11/15 440-2223B INSURER REQUEST FOR

RECONSIDERATIONWC8469 D 01/10 440-1502 INSURER'S REPORTWC8937 D 03/15 440-2333 INSURER'S REQUEST FOR DIRECTOR

APPROVAL OF AN INDEPENDENTMEDICAL EXAMINATION

WC9656 B 10/15 440-3227 INVASIVE MEDICAL PROCEDUREAUTHORIZATION (ENGLISH/SPANISH)

WC8471 G 05/15 440-1644 NOTICE OF CLOSUREWC9799 01/10 440-1644P NOTICE OF CLOSURE - PERMANENT

TOTAL DISABILITY REDUCTIONWC9700 B 05/15 440-1644S NOTICE OF CLOSURE (SPANISH)WC8472 E 01/10 440-2807 NOTICE OF CLOSURE WORKSHEETWC9800 01/10 440-2807A NOTICE OF CLOSURE WORKSHEET

(DATES OF INJURY ON OR AFTER JAN. 1,2005)

WC9428 B 02/16 FORM 2066 NOTICE OF CLOSURE: OWN MOTIONCLAIM

WC9654 A 02/16 FORM 3501 NOTICE OF VOLUNTARY REOPENINGOWN MOTION CLAIM

WC1008 01/18 440-5332 NOTICE TO BENEFICIARY OFENTITLEMENT TO BENEFITS




WC8423 F 01/17 440-3058 NOTICE TO WORKERWC9496 C 01/17 440-3058S NOTICE TO WORKER (SPANISH)WC9429 09/03 44035310903 PHYSICIAN AUTHORIZATION OF

SUPPLEMENTAL DISABILITYWC9989 01/17 440-3014 PREFERRED WORKER PROGRAM

QUARTERLY CLAIM COSTREIMBURSEMENT REQUEST

WC9689 D 01/17 440-2190 PREFERRED WORKER WAGE SUBSIDYAGREEMENT

WC8592 C 06/10 440-2279 RANGE OF MOTION AND DEFORMITY/DEVIATION AMPUTATION ANDSENSATION OF THE UPPER EXTREMITY

WC9655 A 02/16 FORM 1966 REOPENED CLAIMS PROGRAMREIMBURSEMENT REQUEST

WC9188 D 01/17 440-801S REPORT OF JOB INJURY OR ILLNESS(SPANISH)

WC9552 C 01/17 440-801 REPORT OF JOB INJURY OR ILLNESS/UNDERSTANDING WORKERS'COMPENSATION CLAIMS, A GUIDE FORWORKERS RECENTLY HURT ON THE JOB

WC9691 Z 01/18 440-3921 REQUEST FOR REIMBURSEMENT OFEXPENSES

WC9692 Y 01/18 440-3921S REQUEST FOR REIMBURSEMENT OFEXPENSES (SPANISH)

WC8936 B 03/12 440-2476 REQUEST FOR RELEASE OF MEDICALRECORDS FOR OREGON WORKERS'COMPENSATION CLAIM

WC9598 A 03/12 440-2476S REQUEST FOR RELEASE OF MEDICALRECORDS FOR OREGON WORKERS'COMPENSATION CLAIM (SPANISH)

WC8944 K 09/16 440-3088 REQUEST FOR WORKERS'COMPENSATION DIVISION CLAIM FILEINFORMATION

WC9476 C 05/15 440-1644R RESCINDING NOTICE OF CLOSUREWC8591 B 06/10 440-2278C SPINAL RANGE OF MOTIONWC9591 A 11/09 440-3530 SUPPLEMENTAL DISABILITY ELECTION

NOTIFICATIONWC9257 G 01/18 440-2876 UNDERSTANDING CLAIM CLOSURE AND

YOUR RIGHTSWC9258 E 01/18 440-2876S UNDERSTANDING CLAIM CLOSURE AND

YOUR RIGHTS (SPANISH)WC8593 B 05/13 440-2312 VISUAL IMPAIRMENTWC9484 F 01/17 440-2800 VOCATIONAL CLOSURE REPORTWC9624 07/05 44015920705 VOCATIONAL REIMBURSEMENT

REQUESTWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC9972 C 01/18 440-1138 WHAT HAPPENS IF I'M HURT ON THE

JOB? (ENGLISH)WC9973 B 01/18 440-1138S WHAT HAPPENS IF I'M HURT ON THE

JOB? (SPANISH)WC9604 B 01/17 440-2943 WORKER REQUEST FOR CLAIM

CLASSIFICATION REVIEWWC9626 B 01/17 440-2943S WORKER REQUEST FOR CLAIM

CLASSIFICATION REVIEW (SPANISH)WC8607 M 11/15 440-2223A WORKER REQUEST FOR

RECONSIDERATION (ENGLISH)WC9173 H 11/15 440-2223A-S WORKER REQUEST FOR

RECONSIDERATION (SPANISH)WC9483 J 08/16 440-827 WORKER'S AND HEALTH CARE

PROVIDER'S REPORT FOR WORKERS'COMPENSATION CLAIMS




WC9495 H 10/16 440-827S WORKER'S AND HEALTH CAREPROVIDER'S REPORT FOR WORKERS'COMPENSATION CLAIMS (SPANISH)

WC9379 E 11/12 440-2839 WORKERS' COMPENSATION DIVISIONREQUEST FOR HEARING

WC9376 D 01/18 440-2332 WORKER'S REQUEST TO CHANGEATTENDING PHYSICIAN ORAUTHORIZED NURSE PRACTITIONER

PennsylvaniaWC8363 E 04/18 LIBC-338 AGREEMENT FOR COMPENSATION FOR

DEATHWC8364 G 04/18 LIBC-336 AGREEMENT FOR COMPENSATION FOR

DISABILITY OR PERMANENT INJURYWC8377 J 04/18 LIBC-340 AGREEMENT TO STOP WEEKLY

WORKERS' COMPENSATION PAYMENTSFINAL RECEIPT

WC8599 B 04/18 LIBC-35 ANSWER TO PETITION FORCOMMUTATION

WC8300 E 04/18 LIBC-377 ANSWER TO PETITION TO/FOR:WC8302 E 04/18 LIBC-378 ANSWER TO PETITION TO/FOR:WC9263 B 01/18 LICB2526 APPEAL FROM JUDGE'S FINDINGS OF

FACT AND CONCLUSION OF LAWWC7523 C 07/07 LIBC-662 APPLICATION FOR SUPERSEDEAS FUND

REIMBURSEMENTWC7534 D 04/18 LIBC-10 AUTHORIZATION FOR ALTERNATIVE

DELIVERY OF COMPENSATIONPAYMENTS

(New) WC9222 C 04/18 LIBC-375 CLAIM PETITION FOR ADDITIONALCOMPENSATION FROM THESUBSEQUENT INJURY FUND PURSUANTTO SECTION 306.1 OF THE WORKERS'COMPENSATION ACT

WC8600 D 04/18 LIBC-362 CLAIM PETITION FOR WORKERS'COMPENSATION

WC1566 G 04/18 LIBC-498 COMMUTATION OF COMPENSATIONWC8842 H 04/18 LIBC-755 COMPROMISE AND RELEASE

AGREEMENT BY STIPULATIONPURSUANT TO SEC 449 OF THE WC ACT

WC9858 02/11 LIBC-749 DEATH CLAIM SUPPLEMENT TOCOMPROMISE AND RELEASEAGREEMENT

WC8282 E 04/18 LIBC-374 DEFENDANT'S ANSWER TO CLAIMPETITION UNDER PA WORKERS'COMPENSATION ACT

WC8837 B 04/18 LIBC-364B DEFENDANT'S ANSWER TO CLAIMPETITION UNDER PENNSYLVANIAOCCUPATIONAL DISEASE ACT

(New) WC8298 D 04/18 LIBC-134 DISMEMBERMENT CHART(New) WC9823 A 04/18 LIBC-134F DISMEMBERMENT CHART - FOOT

WC8317 C 04/18 LIBC-750 EMPLOYEE REPORT OF WAGES ANDPHYSICAL CONDITION

WC8380 D 04/18 LIBC760 EMPLOYEE VERIFICATION OFEMPLOYMENT, SELF-EMPLOYMENT ORCHANGE IN PHYSICAL CONDITION

WC8458 C 04/18 LIBC756 EMPLOYEE'S REPORT OF BENEFITS FOROFFSETS

WC8839 A 04/04 LIBC3840404 FATAL CLAIM PETITION FORCOMPENSATION BY DEPENDENTSFOR DEATH COVERED BY THEPENNSYLVANIA OCCUPATIONALDISEASE ACT




WC8840 A 02/05 LIBC3860205 FATAL CLAIM PETITION FORCOMPENSATION BY DEPENDENTSFOR DEATH RESULTING FROMOCCUPATIONAL DISEASE

(New) WC8836 C 04/18 LIBC-363 FATAL CLAIM PETITION FORCOMPENSATION BY DEPENDENTS OFDECEASED EMPLOYEES

WC9730 C 04/18 LIBC-392A FINAL STATEMENT OF ACCOUNT OFCOMPENSATION PAID

WC8585 B 09/13 LIBC767 IMPAIRMENT RATING DETERMINATIONFACE SHEET

WC8583 A 09/13 LIBC765 IMPAIRMENT RATING EVALUATIONAPPOINTMENT

(New) WC8333 C 04/18 LIBC754 INFORMAL CONFERENCE AGREEMENTFORM

(New) WC7526 E 04/18 LIBC-9 MEDICAL REPORT FORMWC8338 E 04/18 LIBC-757 NOTICE OF ABILITY TO RETURN TO

WORKWC8582 A 09/13 LIBC764 NOTICE OF CHANGE OF WORKERS'

COMPENSATION DISABILITY STATUSWC8387 C 04/18 LIBC-763 NOTICE OF REINSTATEMENT OF

WORKERS' COMPENSATION BENEFITWC8332 C 04/18 LIBC-753 NOTICE OF REQUEST FOR AN INFORMAL

CONFERENCEWC8386 C 04/18 LIBC-762 NOTICE OF SUSPENSION FOR FAILURE

TO RETURN FORM LIBC-760WC8385 D 04/18 LIBC-761 NOTICE OF WORKERS' COMPENSATION

BENEFIT OFFSETWC8381 A 02/11 LIBC758 NOTICE TO CLAIMANTWC9565 10/04 NOTICE: MEDICAL TREATMENT

FOR YOUR WORK INJURY OROCCUPATIONAL ILLNESS

WC8329 E 04/18 LIBC751 NOTIFICATION OF SUSPENSION ORMODIFICATION PURSUANT TO §§ 413 (C)& (D)

WC8841 D 04/18 LIBC-396 OCCUPATIONAL DISEASE CLAIMPETITION MONTHLY COMPENSATIONFOR DISABILITY UNDER SECTION 301(I)ONLY

WC8598 C 04/18 LIBC-34 PETITION FOR COMMUTATIONOF COMPENSATION UNDERTHE PENNSYLVANIA WORKERSCOMPENSATION ACT OF 1915 ASREENACTED AND AMENDED

WC8316 C 06/04 LIBC6860604 PETITION FOR PENALTIESWC7825 C 04/18 LIBC-499 PETITION FOR PHYSICAL EXAMINATION

OR EXPERT INTERVIEW OF EMPLOYEE(SECTION 314)

(New) WC8372 G 04/18 LIBC-603 PETITION FOR REVIEW OF UTILIZATIONREVIEW DETERMINATION

WC1565 F 04/18 LIBC-497 PHYSICIAN'S AFFIDAVIT OF RECOVERYWC8584 C 09/13 LIBC-766 REQUEST FOR DESIGNATION OF

A PHYSICIAN TO PERFORM ANIMPAIRMENT RATING EVALUATION

WC8281 D 04/18 LIBC494C STATEMENT OF WAGES (FOR INJURIESOCCURRING ON AND AFTER JUNE 24,1966)

WC1562 K 04/18 LIBC-494A STATEMENT OF WAGES (FOR INJURIESOCCURRING ON OR BEFORE JUNE 23,1996)

WC1568 D 04/18 LIBC-339




SUPPLEMENTAL AGREEMENT FORCOMPENSATION FOR DEATH

WC8362 H 04/18 LIBC-337 SUPPLEMENTAL AGREEMENT FORCOMPENSATION FOR DISABILITY ORPERMANENT INJURY

WC8354 E 04/18 LIBC-380 THIRD PARTY SETTLEMENTAGREEMENT

WC9523 03/04 ICR0304 UNIT STATISTICAL PLAN - INDIVIDUALCASE REPORT

WC8360 J 04/18 LIBC-601 UTILIZATION REVIEW REQUESTRhode Island

WC9987 06/16 DWC-EB1 AGREEMENT FOR ELECTRONICPAYMENT OF WORKERS'COMPENSATION BENEFITS

WC8634 C 06/11 DWC11C ELECTION BY EXEMPT CORPORATEOFFICER TO BECOME SUBJECT TOWORKERS' COMPENSATION (TITLE 28CHAPTERS 29 THROUGH 38)

WC1589 A 01/03 DWC-31 EMPLOYEE'S OBJECTION TO WAGETRANSCRIPT

WC8002 F 01/03 DWC020103 MEMORANDUM OF AGREEMENTWC8032 D 01/14 DWC24 MUTUAL AGREEMENTWC8028 G 06/14 DWC-0 NON-PREJUDICIAL AGREEMENTWC8633 C 06/11 DWC11 NOTICE OF COMMON LAW RIGHTS

PURSUANT TO R.I.G.L. SECTION 28-29-17WC1587 C 03/06 DWC-11-IC NOTICE OF DESIGNATION AS

INDEPENDENT CONTRACTOR PURSUANTTO R.I.G.L. §28-29-17.1

WC1588 A 03/06 DWC-11-ICR NOTICE OF WITHDRAWAL OFDESIGNATION AS INDEPENDENTCONTRACTOR PURSUANT TO R.I.G.L§28-29-17.1

WC1553 B 04/02 DWC-29 NOTIFICATION OF CLAIM OFCOMPENSABLE INJURY

WC1550 C 07/09 DWC27/28 PHYSICIAN'S NOTICE OF RELEASE TOWORK

WC8635 B 04/05 DWC400405 REQUEST FOR ADDITIONAL PALLIATIVECARE

WC8844 B 06/11 DWC11R RESCIND NOTICE OF CLAIM OFCOMMON LAW RIGHTS PURSUANT TOR.I.G.L. SECTION 28-29-19

WC9988 06/16 DWC-EB2 RESCISSION OF AGREEMENT FORELECTRONIC PAYMENT OF WORKERS'COMPENSATION BENEFITS

WC8018 C 01/03 DWC050103 SUSPENSION AGREEMENT AND RECIEPTWC9928 01/14 DWC-21 TERMINATION OF BENEFITSWC8268 A 08/05 MAB020805 WAIVER OF MEDICAL REVIEWWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

South CarolinaWC7669 C 09/07 WCCFORM160907 AGREEMENT FOR PERMANENT

DISABILITY/DISFIGUREMENTCOMPENSATION

WC9735 D 10/17 FORM #16 AGREEMENT FOR PERMANENTDISABILITY/DISFIGUREMENTCOMPENSATION

WC8132 D 05/06 12M ANNUAL MINOR MEDICAL REPORTWC1007 10/17 FORM 59 APPELLANT’S INFORMAL BRIEFWC9107 A 01/86 S-2 APPLICATION FOR LUMP SUM AWARDWC9103 A 09/90 24 APPLICATION FOR LUMP SUM AWARDWC9105 D 07/08 61 ATTORNEY FEE PETITIONWC8136 D 07/13 FORM #50




EMPLOYEE'S NOTICE OF CLAIM AND/ORREQUEST FOR HEARING

WC8138 B 07/13 FORM #52 EMPLOYEE'S NOTICE OF CLAIM AND/ORREQUEST FOR HEARING, DEATH CASE

WC8137 E 07/15 FORM #51 EMPLOYER'S ANSWER TO REQUEST FORHEARING

WC8139 B 07/13 FORM #53 EMPLOYER'S ANSWER TO REQUEST FORHEARING, DEATH CASE

WC8904 B 07/13 FORM #54 EMPLOYER'S NOTICE OF CLAIM AND/ORREQUEST FOR HEARING

WC7737 D 07/15 FORM #21 EMPLOYER'S REQUEST FOR HEARINGWC9108 A 01/86 S-3 ENTITLEMENT TO RIGHT OF ACTIONWC8902 B 04/06 12A FIRST REPORT OF INJURY OR ILLNESSWC8903 A 05/06 WCCFORM14A0506 HEALTH INSURANCE CLAIM FORMWC9582 11/04 MEDICAL QUESTIONNAIRE (SIF)WC9580 A 11/07 NOTICE OF POSSIBLE SECOND INJURY

FUND CLAIMWC9106 B 01/86 S1 NOTICE OF THIRD PARTY ACTION

EMPLOYER CARRIERWC8116 F 01/14 FORM 18 PERIODIC REPORTWC9740 C 12/16 FORM #14B PHYSICIAN'S STATEMENTWC8140 E 07/15 FORM 58 PRE-HEARING BRIEFWC7670 C 01/14 FORM 17 RECEIPT OF COMPENSATIONWC8135 C 07/13 FORM #30 REQUEST FOR COMMISSION REVIEWWC9104 B 07/03 32 REQUEST TO WAIVE APPEAL FILING FEEWC9581 11/04 SECOND INJURY FUND

REIMBURSEMENT REQUEST FORMWC9371 B 07/13 FORM 55 SECOND INJURY FUND'S ANSWER TO

EMPLOYER'S REQUEST FOR HEARINGWC7675 C 01/14 FORM 20 STATEMENT OF EARNINGS OF INJURED

EMPLOYEEWC7648 H 01/14 FORM 19 STATUS REPORT AND COMPENSATION

RECEIPTWC8758 B 03/14 FORM 27 SUBPOENAWC7668 B 03/97 WCCFORM15S0397 SUPPLEMENTAL REPORT OF VARYING

TEMPORARY PARTIAL PAYMENTSWC7667 D 01/14 FORM 15 TEMPORARY COMPENSATION REPORTWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

South DakotaWC7637 J 02/17 DLR-LM-110 CALCULATION OF COMPENSATIONWC7602 N 02/17 DLR-LM-101 EMPLOYER'S FIRST REPORT OF INJURYWC7985 B 09/01 INTAKE FORM CONFIDENTIALWC8464 E 02/17 DLR-LM-111 MEMORANDUM OF PAYMENT FOR

PERMANENT PARTIAL DISABILITYWC1538 F 02/17 DLR-LM-113 MEMORANDUM OF PAYMENT FOR

REHABILITATIONWC8463 H 02/17 DLR-LM-107 MONTHLY PAYMENT REPORTWC9955 A 03/17 SAFETY ON THE JOB POSTING (ENGLISH)WC9956 A 03/17 SAFETY ON THE JOB POSTING (SPANISH)WC8733 10/95 IA21095 WC SUBSEQUENT REPORT

TennesseeWC9957 A 11/15 C-42 SP AGREEMENT BETWEEN EMPLOYER/

EMPLOYEE CHOICE OF PHYSICIAN(SPANISH)

WC9111 C 11/15 C-39 APPLICATION FOR REGISTRATION FORUTILIZATION REVIEW ORGANIZATION

WC8446 F 03/15 C-30 ATTENDING PHYSICIAN REPORTWC8399 C 12/07 C-34 CASE MANAGEMENT CLOSUREWC8398 E 12/16 C-33 CASE MANAGEMENT NOTIFICATIONWC9110 E 11/16 C-38 CASE MANAGER REGISTRATIONWC7754 K 11/15 C-42 EMPLOYEE'S CHOICE OF PHYSICIAN




WC8323 K 12/07 C20LB00211201 EMPLOYER'S FIRST REPORT OFWORKINJURY OR ILLNESS

WC7599 F 01/17 C-30A FINAL MEDICAL REPORTWC7508 G 12/07 C-29 FINAL REPORT OF PAYMENT AND

RECEIPT OF COMPENSATIONWC8393 F 11/15 C-31 MEDICAL WAIVER AND CONSENT

(New) WC7726 E 04/18 C-26 NOTICE OF CHANGE OR TERMINATIONOF COMPENSATION BENEFITS

WC7727 D 03/16 C-27 NOTICE OF CONTROVERSYWC1537 F 11/15 C-23 NOTICE OF DENIAL OF CLAIM FOR

COMPENSATIONWC8048 F 12/07 C22LB00241207 NOTICE OF FIRST PAYMENT OF

COMPENSATIONWC7578 C 12/07 C-28 NOTICE OF LAWSUITWC9934 C 02/18 LB-1095 PETITION FOR BENEFIT

DETERMINATIONWC9825 06/10 C-44 REQUEST FOR ADMINISTRATIVE

REVIEW OF A WORKERS'COMPENSATION SPECIALIST'S ORDER

WC9533 M 02/18 LB-0381 REQUEST FOR BENEFIT REVIEWCONFERENCE

WC8578 G 11/17 C-32 STANDARD FORM MEDICAL REPORTFOR INDUSTRIAL INJURIES

WC8580 B 12/07 C-36/C-37 UTILIZATION REVIEW CLOSUREWC8579 D 12/07 C-35 UTILIZATION REVIEW NOTIFICATIONWC7741 F 11/15 C-41 WAGE STATEMENTWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC8787 E 06/16 SD1 WORKERS' COMPENSATION

STATISTICAL DATA FORMTexas

WC9777 10/13 DWC105 ACCIDENT PREVENTION SERVICESWORKSHEET

WC9431 11/03 AFFIDAVIT OF NON-EXISTENCE OFBUSINESS RECORDS

WC7657 G 02/17 DWC031 APPLICATION FOR DIVISION APPROVALOF CHANGE IN PAYMENT PERIOD AND/OR PURCHASE OF AN ANNUITY FORDEATH BENEFITS

WC8874 E 02/17 DWC035 APPLICATION FOR DIVISION APPROVALOF THE PURCHASE OF AN ANNUITY FORLIFETIME INCOME BENEFITS

WC8096 J 02/17 DWC052 APPLICATION FOR SUPPLEMENTALINCOME BENEFITS (ENGLISH)

WC7734 H 02/17 DWC052S APPLICATION FOR SUPPLEMENTALINCOME BENEFITS (SPANISH)

WC8544 F 11/17 DWC024 BENEFIT DISPUTE AGREEMENTWC8545 F 11/17 DWC025 BENEFIT DISPUTE SETTLEMENTWC9430 11/03 BUSINESS RECORD AFFIDAVITWC7768 E 02/17 DWC033 CARRIER'S REQUEST FOR REDUCTION

OF INCOME BENEFITS DUE TOCONTRIBUTION

WC8938 E 02/17 DWC056 CARRIER'S REQUEST FOR SEASONALEMPLOYEE WAGE INFORMATION FROMTEXAS EMPLOYMENT COMMISSIONRECORDS

WC9766 D 03/16 DWC042 CLAIM FOR WORKERS' COMPENSATIONDEATH BENEFITS (ENGLISH)

WC9767 D 03/16 DWC042S CLAIM FOR WORKERS' COMPENSATIONDEATH BENEFITS (SPANISH)

WC9793 09/09 DWC 074 DESCRIPTION OF INJURED EMPLOYEE’SEMPLOYMENT




WC9887 B 02/17 DWC068 DESIGNATED DOCTOR EXAMINATIONDATA REPORT

WC7926 E 06/12 DWC044 ELECTION TO ENGAGE IN ARBITRATIONWC8875 H 03/12 DWC-053S EMPLOYEE REQUEST TO CHANGE

TREATING DOCTOR (SPANISH)WC8616 G 02/17 DWC047 EMPLOYEE’S REQUEST FOR ADVANCE

OF BENEFITS (ENGLISH)WC8617 G 02/17 DWC047S EMPLOYEE’S REQUEST FOR ADVANCE

OF BENEFITS (SPANISH)WC7655 K 03/07 DWC041 EMPLOYEE'S CLAIM FOR

COMPENSATION FOR A WORK-RELATEDINJURY OR OCCUPATIONAL DISEASE(DWC FORM-041) (ENGLISH)

WC9584 D 03/07 DWC041S EMPLOYEE'S CLAIM FORCOMPENSATION FOR A WORK-RELATEDINJURY OR OCCUPATIONAL DISEASE(DWC FORM-041S)(SPANISH)

WC8632 F 02/17 DWC051 EMPLOYEE'S ELECTION FOR COMMUTED(LUMP SUM) IMPAIRMENT INCOMEBENEFITS

WC9183 F 04/16 DWC003ME EMPLOYEE'S MULTIPLE EMPLOYMENTWAGE STATEMENT

WC9218 F 04/16 DWC003MES EMPLOYEE'S MULTIPLE EMPLOYMENTWAGE STATEMENT (SPANISH)

WC8614 B 10/05 DWC461005 EMPLOYEE'S REQUEST FORACCELERATION OF IMPAIRMENTINCOME BENEFITS (ENGLISH)

WC8615 C 10/05 DWC46S1005 EMPLOYEE'S REQUEST FORACCELERATION OF IMPAIRMENTINCOME BENEFITS (SPANISH)

WC8816 E 11/08 DWC004 EMPLOYER'S CONTEST OFCOMPENSABILITY

WC7631 G 10/05 DWC001 EMPLOYER'S FIRST REPORT OF INJURYOR ILLNESS

WC8704 D 02/17 DWC-2 EMPLOYER'S REPORT FORREIMBURSEMENT OF VOLUNTARYPAYMENT

WC7635 G 10/05 DWC003 EMPLOYER'S WAGE STATEMENT(ENGLISH)

WC9220 C 10/05 DWC003S EMPLOYER'S WAGE STATEMENT(SPANISH)

WC9182 C 10/05 DWC3SD1005 EMPLOYER'S WAGE STATEMENT FORSCHOOL DISTRICTS

WC9219 C 10/05 DWC3SDS1005 EMPLOYER'S WAGE STATEMENT FORSCHOOL DISTRICTS (SPANISH)

WC9906 07/12 INJURED EMPLOYEE NOTIFICATIONLETTER FOR PHARMACY CLOSEDFORMULARY LEGACY CLAIMS

WC8547 P 06/12 DWC060 MEDICAL FEE DISPUTE RESOLUTIONREQUEST / RESPONSE

WC9587 A 10/05 DWC751005 NON-ADL DOCTOR REQUEST FOR CASE-BY-CASE EXCEPTION

WC9514 D 09/17 PLN08 NOTICE OF CHANGE IN AMOUNT OFINDEMNITY BENEFIT PAYMENT

WC9835 A 09/17 PLN08S NOTICE OF CHANGE IN AMOUNTOF INDEMNITY BENEFIT PAYMENT(SPANISH)

WC9513 D 09/17 PLN07 NOTICE OF CHANGE OF INDEMNITYBENEFIT TYPE

WC9834 A 09/17 PLN07S NOTICE OF CHANGE OF INDEMNITYBENEFIT TYPE (SPANISH)




WC9507 D 09/17 PLN01 NOTICE OF DENIAL OFCOMPENSABILITY/LIABILITY ANDREFUSAL TO PAY BENEFITS

WC9828 A 09/17 PLN01S NOTICE OF DENIAL OFCOMPENSABILITY/LIABILITY ANDREFUSAL TO PAY BENEFITS (SPANISH)

WC9517 E 09/17 PLN11 NOTICE OF DISPUTED ISSUE(S) ANDREFUSAL TO PAY BENEFITS

WC9838 B 09/17 PLN11S NOTICE OF DISPUTED ISSUE(S) ANDREFUSAL TO PAY BENEFITS (SPANISH)

WC9510 E 09/17 PLN04 NOTICE OF ELIGIBILITY FOR LIFETIMEINCOME BENEFITS

WC9831 B 09/17 PLN04S NOTICE OF ELIGIBILITY FOR LIFETIMEINCOME BENEFITS (SPANISH)

WC9512 D 09/17 PLN06 NOTICE OF EMPLOYER FULL SALARYPAYMENT

WC9833 A 09/17 PLN06S NOTICE OF EMPLOYER FULL SALARYPAYMENT (SPANISH)

WC9511 D 09/17 PLN5 NOTICE OF FIRST DEATH BENEFITPAYMENT

WC9832 A 09/17 PLN05S NOTICE OF FIRST DEATH BENEFITPAYMENT (SPANISH)

WC9829 A 09/17 PLN02S NOTICE OF FIRST TEMPORARY INCOMEBENEFIT PAYMENT (SPANISH)

WC9688 D 06/12 OMB-49S NOTICE OF INJURED EMPLOYEE RIGHTSAND RESPONSIBILITIES IN THE TEXASWORKERS' COMPENSATION SYSTEM(SPANISH)

WC9687 D 06/12 OMB-49 NOTICE OF INJURED EMPLOYEE RIGHTSAND RESPONSIBILITIES IN THE TEXASWORKERS’ COMPENSATION SYSTEM

WC1005 09/17 PLN03C NOTICE OF MAXIMUM MEDICALIMPROVEMENT AND ESTIMATEDPERMANENT IMPAIRMENT

WC1006 09/17 PLN03CS NOTICE OF MAXIMUM MEDICALIMPROVEMENT AND ESTIMATEDPERMANENT IMPAIRMENT (SPANISH)

WC1001 09/17 PLN03A NOTICE OF MAXIMUM MEDICALIMPROVEMENT AND NO PERMANENTIMPAIRMENT

WC1002 09/17 PLN03AS NOTICE OF MAXIMUM MEDICALIMPROVEMENT AND NO PERMANENTIMPAIRMENT (SPANISH)

WC1003 A 09/17 PLN03B NOTICE OF MAXIMUM MEDICALIMPROVEMENT AND PERMANENTIMPAIRMENT

WC1004 A 09/17 PLN03BS NOTICE OF MAXIMUM MEDICALIMPROVEMENT AND PERMANENTIMPAIRMENT (SPANISH)

WC9889 A 09/17 PLN12 NOTICE OF POTENTIAL ENTITLEMENTTO WORKERS’ COMPENSATION DEATHBENEFITS

WC1000 09/17 PLN12S NOTICE OF POTENTIAL ENTITLEMENTTO WORKERS’ COMPENSATION DEATHBENEFITS (SPANISH)

WC9516 D 09/17 PLN10 NOTICE OF REINSTATEMENT OFINDEMNITY BENEFITS

WC9837 A 09/17 PLN10S NOTICE OF REINSTATEMENT OFINDEMNITY BENEFITS (SPANISH)

WC9567 C 12/16 DWC-150 NOTICE OF REPRESENTATIONWC9515 D 09/17 PLN09




NOTICE OF SUSPENSION OF INDEMNITYBENEFITS

WC9836 A 09/17 PLN09S NOTICE OF SUSPENSION OF INDEMNITYBENEFITS (SPANISH)

WC9663 10/05 DWC54S1005 NOTICE TO EMPLOYEE: INTENTION TOREQUEST DIVISION PERMISSION TOADJUST BENEFITS

WC8756 D 02/17 DWC54 NOTICE TO EMPLOYEE: INTENTION TOREQUEST DIVISION PERMISSION TOADJUST BENEFITS

WC9511 C 10/05 DWCPLN51005 NOTIFICATION OF FIRST DEATH BENEFITPAYMENT

WC9508 D 09/17 PLN02 NOTIFICATION OF FIRST TEMPORARYINCOME BENEFIT PAYMENT

WC9509 C 10/05 DWCPLN31005 NOTIFICATION OF MAXIMUM MEDICALIMPROVEMENT/FIRST IMPAIRMENTINCOME BENEFIT PAYMENT

WC9830 08/10 PLN003S NOTIFICATION OF MAXIMUM MEDICALIMPROVEMENT/FIRST IMPAIRMENTINCOME BENEFIT PAYMENT (SPANISH)

WC9907 07/12 PHARMACY CLOSED FORMULARYNOTIFICATION LETTER FOR LEGACYCLAIMS

WC9905 07/12 PHYSICIAN NOTIFICATION LETTERFOR PHARMACY CLOSED FORMULARYLEGACY CLAIMS

WC8128 F 10/05 DWC1561005 PROSPECTIVE EMPLOYMENTAUTHORIZATION AND CERTIFICATION

WC8638 F 10/06 DWC156S1006 PROSPECTIVE EMPLOYMENTAUTHROIZATION AND CERTIFICATION -SPANISH VERSION

WC8504 G 10/06 DWC1531006 REQUEST FOR COPY OF CONFIDENTIALCLAIMANT INFORMATION

WC7761 N 01/13 DWC032 REQUEST FOR DESIGNATED DOCTOREXAMINATION

WC9768 C 01/13 DWC032S REQUEST FOR DESIGNATED DOCTOREXAMINATION (SPANISH)

WC8880 E 02/17 DWC057 REQUEST FOR EXTENSION OF MAXIMUMMEDICAL IMPROVEMENT FOR SPINALSURGERY

WC8685 D 10/05 DWC1551005 REQUEST FOR RECORD CHECKWC8757 D 02/17 DWC055 REQUEST TO ADJUST AVERAGE WEEKLY

WAGE FOR SEASONAL EMPLOYEEWC9664 B 02/17 DWC055S REQUEST TO ADJUST AVERAGE WEEKLY

WAGE FOR SEASONAL EMPLOYEE(SPANISH)

WC7769 K 03/12 DWC053 REQUEST TO CHANGE TREATINGDOCTOR

WC8853 G 02/17 DWC048 REQUEST TO GET REIMBURSED FORTRAVEL COSTS (ENGLISH)

WC9966 A 02/17 DWC048S REQUEST TO GET REIMBURSED FORTRAVEL COSTS (SPANISH)

WC9883 C 11/17 DWC049 REQUEST TO SCHEDULE A MEDICALCONTESTED CASE HEARING (MCCH)

WC9998 07/17 DWC045 REQUEST TO SCHEDULE, RESCHEDULE,OR CANCEL A BENEFIT REVIEWCONFERENCE (BRC), OR TO PROCEEDDIRECTLY TO CONTESTED CASEHEARING (CCH) - ENGLISH

WC7565 G 07/17 DWC-45 REQUEST TO SCHEDULE, RESCHEDULE,OR CANCEL A BENEFIT REVIEW




CONFERENCE (BRC), OR TO PROCEEDDIRECTLY TO CONTESTED CASEHEARING (CCH) - ENGLISH

WC9999 07/17 DWC045S REQUEST TO SCHEDULE, RESCHEDULE,OR CANCEL A BENEFIT REVIEWCONFERENCE (BRC), OR TO PROCEEDDIRECTLY TO CONTESTED CASEHEARING (CCH) - SPANISH

WC9881 B 02/17 DWC045M REQUEST TO SCHEDULE, RESCHEDULE,OR CANCEL A BENEFIT REVIEWCONFERENCE TO APPEAL A MEDICALFEE DISPUTE DECISION (BRC-MFD)

WC9882 B 02/17 DWC045MS REQUEST TO SCHEDULE, RESCHEDULE,OR CANCEL A BENEFIT REVIEWCONFERENCE TO APPEAL A MEDICALFEE DISPUTE DECISION (BRC-MFD) -SPANISH

WC7651 K 07/11 DWC022 REQUIRED MEDICAL EXAMINATION -REQUEST FOR AGREEMENT / REQUESTFOR ORDER

WC9873 07/11 DWC022S REQUIRED MEDICAL EXAMINATION(RME) - REQUEST FOR AGREEMENT /REQUEST FOR ORDER (SPANISH)

WC9503 E 12/11 DWC066 STATEMENT OF PHARMACY SERVICES(New) WC1014 02/18 SD-2 STATISTICAL DATA FORM FOR INJURIES

ON/AFTER JULY 1, 2014WC7795 E 10/05 DWC006 SUPPLEMENTAL REPORT OF INJURYWC8802 G 02/11 DWC73 TEXAS WORKERS' COMPENSATION

WORK STATUS REPORTWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC9971 A 03/13 WHAT EMPLOYERS NEED TO KNOW

ABOUT RETURN-TO-WORK INITIATIVESIN TEXAS

WC9701 A 09/07 DWC0580907 WRITTEN REQUEST FORINTERLOCUTORY ORDER (DWCFORM-058)

UtahWC9024 C 03/12 FORM 025 APPLICATION FOR HEARING -

DEPENDENT'S BENEFITS AND/ORBURIAL BENEFITS (INDUSTRIALACCIDENT CLAIM)

WC9861 B 05/16 FORM 027 APPLICATION FOR HEARING -DEPENDENT'S BENEFITS AND/ORBURIAL BENEFITS (OCCUPATIONALDISEASE CLAIM)

WC9022 J 10/16 FORM 001 APPLICATION FOR HEARING(INDUSTRIAL ACCIDENT CLAIM)

WC9860 D 05/16 FORM 026 APPLICATION FOR HEARING(OCCUPATIONAL DISEASE CLAIM)

WC9023 E 06/14 FORM 024 APPLICATION FOR HEARING MEDICALCARE PROVIDER

WC8535 F 05/16 FORM 134 APPLICATION FOR LUMP SUM ORADVANCE PAYMENT

WC7584 F 10/14 FORM-102 APPLICATION TO CHANGE DOCTORSWC9026 H 06/16 FORM 152 APPOINTMENT OF COUNSELWC8531 C 10/16 FORM 043 ATTENDING PHYSICIAN'S STATEMENTWC9936 C 10/14 FORM 800 ATTORNEY FEE APPROVALWC8630 E 03/17 UNCON AUTHORIZATION REQUEST FOR

MEDICAL PROCEDURE/CARRIERRESPONSE

WC7583 F 10/04 0460603




AUTHORIZATION TO RELEASE LABORCOMMISSION RECORDS

WC8534 G 10/14 FORM 089 EMPLOYEE NOTIFICATION OF DENIALOR PARTIAL DENIAL OF CLAIM

WC8533 D 10/16 FORM 44 EMPLOYEE'S NOTIFICATION OF INTENTTO LEAVE LOCALITY OR STATE, AND TOCHANGE DOCTOR OR HOSPITAL

WC7551 G 03/17 FORM 122/FORM 100 EMPLOYER’S FIRST REPORT OF INJURYOR ILLNESS (INCLUDES INJUREDWORKER RIGHTS & RESPONSIBILITIESSHEET)

WC7628 A 07/17 FORM 141 INITIAL STATEMENT OF INSURANCECARRIER OR SELF-INSURER WITHRESPECT TO PAYMENT OF BENEFITS

WC8536 C 10/09 FORM206 INJURED WORKER STATUS REPORTWC8538 F 10/14 FORM 441 INSURANCE CARRIERS / SELF INSURER’S

NOTICE OF FURTHER INVESTIGATION OFA WORKERS’ COMPENSATION CLAIM

WC7617 H 10/14 FORM 130 INSURANCE COMPANY’S AND SELFINSURER’S FINAL REPORT OF INJURYAND STATEMENT OF TOTAL LOSSES

WC9629 C 10/14 FORM 198 INSURER REQUEST FOR EXTENSION OFTIME TO OBTAIN 2ND DENTAL OPINION

WC9798 10/09 FORM 239 INSURER/EMPLOYER QUARTERLYREPORT ON REEMPLOYMENT EFFORTS

WC9797 10/09 FORM 215 INSURER/EMPLOYER REQUEST TOWAIVE/POSTPONE REEMPLOYMENTREFERRAL

WC7540 P 06/16 FORM 219 PERMANENT PARTIAL DISABILITYCOMPENSATION WORKSHEET

WC7605 F 10/14 FORM 123 PHYSICIANS' INITIAL REPORT OF WORKINJURY OR OCCUPATIONAL DISEASE

WC9630 B 02/09 FORM310 REQUEST/APPEAL FOR ADDITIONALMEDICAL INFORMATION

WC9885 07/12 FORM 221C RESTORATIVE SERVICESAUTHORIZATION/DENIAL - LOWEREXTREMITY

WC8629 C 07/12 FORM 221A RESTORATIVE SERVICESAUTHORIZATION/DENIAL - SPINE

WC9884 07/12 FORM 221B RESTORATIVE SERVICESAUTHORIZATION/DENIAL - UPPEREXTREMITY

WC9802 03/10 FORM 113B SUMMARY OF MEDICAL RECORD -OCCUPATIONAL EXPOSURE

WC8733 10/95 IA21095 WC SUBSEQUENT REPORTVermont

WC9418 B 08/16 FORM 13A AGGREGATE ANNUAL REPORTINGFORM-REPORTING PERIOD 7/01-6/30

WC8155 G 06/10 FORM 23 AGREEMENT FOR COMPENSATION INFATAL CASES

WC8154 K 06/10 FORM 22 AGREEMENT FOR PERMANENT PARTIALOR PERMANENT TOTAL DISABIITYCOMPENSATION

WC8149 M 12/17 FORM 32 AGREEMENT FOR TEMPORARYCOMPENSATION

WC8147 F 09/11 FORM 10 CERTIFICATE OF DEPENDENCY ANDCONCURRENT EMPLOYMENT

WC8805 H 04/18 FORM 2 DENIAL OF WORKERS’ COMPENSATIONBENEFITS BY EMPLOYER OR CARRIER

WC9874 08/11 VR 227




DENIAL/DISCONTINUANCE OFVOCATIONAL REHABILITATION BYEMPLOYER OR CARRIER

WC8143 F 09/11 FORM 5 EMPLOYEE’S NOTICE OF INJURY ANDCLAIM FOR COMPENSATION

WC8170 V 09/11 FORM 1/FORM 8 EMPLOYER FIRST REPORT OF INJURY(INCLUDES NOTICE OF INTENT TOCHANGE HEALTH CARE PROVIDER)

(New) WC8160 S 05/18 FORM 27 EMPLOYER'S NOTICE OF INTENTION TODISCONTINUE PAYMENTS

WC9150 D 02/07 ENTITLEMENT ASSESSMENTWC8408 J 01/17 FORM 7 MEDICAL AUTHORIZATIONWC9716 C 01/15 FORM 25M MEMORANDUM OF PAYMENTWC8144 G 09/11 FORM 6 NOTICE AND APPLICATION FOR

HEARING(New) WC9818 J 05/18 FORM 28 FY19 NOTICE OF CHANGE IN COMPENSATION

RATE (FOR INJURIES AFTER JULY 1, 1986)(New) WC9819 J 05/18 FORM 28A FY19 NOTICE OF CHANGE IN COMPENSATION

RATE (FOR INJURIES BEFORE JULY 1,1986)

WC9145 E 08/13 FORM VR8 NOTICE OF INTENT TO CHANGEVOCATIONAL REHABILITATIONPROVIDER

WC8175 K 09/09 DOL FORM 13 REPORT OF BENEFITS AND RELATEDEXPENSES PAID

WC8142 E 09/11 FORM4 REPORT OF FATAL ACCIDENTWC9151 D 02/07 RETURN TO WORK PLANWC8336 J 07/14 FORM 16 SETTLEMENT AGREEMENTWC9148 G 02/07 VOCATIONAL REHABILITATION COVER

PAGEWC9144 G 12/14 VOCATIONAL REHABILITATION

DISCLOSURE STATEMENTWC9149 F 02/07 VOCATIONAL REHABILITATION

DISCONTINUANCE REPORTWC9152 D 02/07 VOCATIONAL REHABILITATION

PROGRESS REPORTWC8539 J 08/13 VOCATIONAL REHABILITATION

REFERRAL FORMWC8340 F 06/10 FORM 25 WAGE STATEMENTWC9751 D 01/18 FORM 25 WAGE STATEMENT - INJURIES ON OR

AFTER JULY 1, 2008WC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC8411 E 09/09 DOL FORM 25S WEEKLY NET INCOME WORKSHEETWC8901 C 12/10 FORM 20 WORK CAPABILITIES FORM

VirginiaWC7876 A 10/91 FORM 7 AMPUTATION CHARTWC7896 D 01/13 FORM 6 ATTENDING PHYSICIAN'S REPORTWC9762 A 04/12 CSD 50 AWARD AGREEMENT (VA)WC7885 F 04/09 FORM 5A EMPLOYER'S APPLICATION FOR

HEARINGWC9764 A 04/12 CSD-101 FATAL AWARD AGREEMENT (VA)WC8045 M 10/08 FORM 3 FIRST REPORT OF INJURY (FOR DATES

OF ACCIDENT PRIOR TO 10/01/2008)WC9970 06/14 PANEL PHYSICIANS FORMWC9668 A 10/17 REQUEST FOR EXPEDITED HEARINGWC9112 D 03/18 REQUEST FOR MEDIATIONWC9113 08/01 PR500801 REQUEST FOR PEER REVIEWWC9573 A 01/05 VWC4G0105 SUPPLEMENTAL AGREEMENT TO

PAY VARYING TEMPORARY PARTIALBENEFITS

WC7527 B 09/99 VWC3A0999 SUPPLEMENTARY REPORT




WC9763 B 04/12 CSD 133 TERM OF WAGE LOSS AWARD (VA)WC8056 G 07/06 FORM 7A WAGE CHARTWC8733 10/95 IA21095 WC SUBSEQUENT REPORT

WashingtonWC9467 E 01/18 F245-037-000 CASE TRANSFER CARDWC9535 H 04/17 F242-420-000 DECLARATION OF ENTITLEMENT

(SURVIVING SPOUSE/REGISTEREDDOMESTIC PARTNER)

WC9537 G 04/17 F242-422-000 DECLARATION OF ENTITLEMENTFOR DEPENDENT OF DECEASEDWORKER BENEFITS UNDER INDUSTRIALINSURANCE

WC9536 G 02/17 F242-421-000 DECLARATION OF ENTITLEMENTFOR GUARDIAN BENEFITS UNDERINDUSTRIAL INSURANCE

WC9538 H 02/17 F242-423-000 DECLARATION OF ENTITLEMENT FORTOTALLY DISABLED WORKER BENEFITSUNDER INDUSTRIAL INSURANCE

WC9470 B 09/07 F242-387-000 DOCTOR'S ESTIMATE OF PHYSICALCAPACITIES

WC9543 F 03/16 F252-040-000 EMPLOYER’S JOB DESCRIPTIONWC9465 A 06/15 F262-013-000 EMPLOYMENT HISTORY - HEARING LOSSWC9541 09/00 F2520070000900 HEARING IMPAIRMENT CALCULATION

WORKSHEETWC9165 G 07/16 LEP LOSS OF EARNING POWER (LEP)

CALCULATIONSWC9466 A 06/15 F262-016-000 OCCUPATIONAL HEARING LOSS

QUESTIONNAIREWC9544 07/02 F2620169990702 OCCUPATIONAL HEARING LOSS

QUESTIONNAIRE (SPANISH)WC9469 B 06/17 F242-430-000 REQUEST FOR CLAIM INFORMATIONWC9542 04/02 F252350000402 SAMPLE JOB OFFER LETTERWC9534 A 08/13 F207-070-000 SELF INSURED EMPLOYERS' TIME LOSS

CLAIM CLOSURE ORDER AND NOTICEWC9124 A 09/07 SIF50907 SI REPORT ON OCCUPATIONAL INJURY

OR DISEASEWC9540 03/02 F2492070000302 THIRD PARTY ELECTION FORMWC9125 F 04/17 SIF-5A TOTAL MONTHLY WAGE

CALCULATIONSWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC9539 E 10/15 F242052000 WORK STATUS FORM

West VirginiaWC9745 05/08 OIC-WC-1 EMPLOYEES' AND PHYSICIANS' REPORT

OF OCCUPATIONAL INJURY OR DISEASEWC9746 05/08 OIC-WC-2 EMPLOYERS' REPORT OF

OCCUPATIONAL INJURY OR DISEASEWC9839 10/10 INITIAL NOTICE TO RECIPIENTS OF

104-WEEK AWARD PAID IN MONTHLYPAYMENTS

WC9840 10/10 NOTICE TO RECIPIENTS OF 104-WEEKAWARD PAID IN A LUMP SUM

WC9841 10/10 SECOND NOTICE TO RECIPIENTS OF104-WEEK AWARD PAID IN MONTHLYPAYMENTS

WC8733 10/95 IA21095 WC SUBSEQUENT REPORTWisconsin

(New) WC9180 G 05/18 WKC-19 ADMISSION TO SERVICE AND ANSWERTO APPLICATION

WC7931 C 07/01 WKC1360701 ADVANCEMENT OR LUMP SUM REQUESTWC9963 A 06/17 WKC-17876 ANNUAL REPORT OF PERMANENT

TOTAL DISABILITY PAYMENTS MADE




WC7973 E 07/16 WKC-176 COMPROMISE AGREEMENTWC9372 B 06/17 WKC-7-B COMPROMISE REVIEW APPLICATIONWC8161 C 06/17 WKC-12 EMPLOYER'S FIRST REPORT OF INJURY

OR DISEASEWC9959 08/04 WKC-14306-P INFORMATION FOR EMPLOYEES

ON WISCONSIN'S WORKER'SCOMPENSATION (ENGLISH)

WC9960 08/04 WKC-14306-S-P INFORMATION FOR EMPLOYEESON WISCONSIN'S WORKER'SCOMPENSATION (SPANISH)

WC7907 K 06/17 WKC16 MEDICAL REPORT ON INDUSTRIALINJURY

WC8203 G 06/17 WKC3 MEDICAL TREATMENT STATEMENTWC9373 E 06/17 WKC-9380 NECESSITY OF TREATMENT DISPUTE

RESOLUTION REQUEST(New) WC7932 F 05/18 WKC-28-DHA PETITION FOR REVIEW OF FINDINGS

AND ORDER OF ADMINISTRATIVE LAWJUDGE

WC7911 G 06/17 WKC-16-A PHYSICIAN'S REPORT ON EYE INJURIESWC7930 J 07/16 WKC-16-B PRACTITIONER'S REPORT ON ACCIDENT

OR INDUSTRIAL DISEASE IN LIEU OFTESTIMONY

WC9444 B 06/17 WKC10369 PRIVATE VOCATIONALREHABILITATION SERVICESQUARTERLY REPORT

WC9506 D 06/17 WKC-9498 REASONABLENESS OF FEE DISPUTERESOLUTION REQUEST

WC8129 D 07/16 WKC-177 STIPULATION(New) WC9179 C 05/18 WKC-17-DHA-E SUBPOENA

WC8737 E 06/17 WKC-140 SUPPLEMENTAL PAYMENTSREIMBURSEMENT REQUEST

WC8162 P 06/17 WKC13 SUPPLEMENTARY REPORT ONACCIDENTS AND INDUSTRIAL DISEASES

WC7672 D 07/16 WKC-170 THIRD PARTY PROCEEDS DISTRIBUTIONAGREEMENT

WC9443 C 06/17 WKC-6743 VOCATIONAL EXPERT REPORTWC7693 J 06/17 WKC-13A WAGE INFORMATION SUPPLEMENTWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC9958 11/14 WKC-10539-P WE'RE PROTECTED BY WORKER'S

COMPENSATIONWC9374 B 06/17 WKC-35 WORKER'S COMPENSATION

PREHEARING AND HEARINGAPPEARANCE PERMIT APPLICATION

WC7903 G 02/09 WKC-7359 WORKSHEET FOR TEMPORARY PARTIALDISABILITY

WyomingWC8733 10/95 IA21095 WC SUBSEQUENT REPORTWC9875 11/11 INJRPT WYOMING REPORT OF INJURY

Documents

Workers’ Compensation Claim Forms - Wolters Kluwerfrg.wolterskluwerfs.com/Workers_Compensation_Claims.pdfThe Workers Compensation Claim Forms listed in ... Forms are in text provided