| Claims
Adjusting forms |
Revised |
 Form
1 (4-Sided Form) |
First Report
of Injury or Illness |
01/01/2002 |
| Form
2 (2-Sided Form) |
Employer's
Intent to Accept or Controvert |
01/01/2013 |
| Form
3 (2-Sided Form) |
Physician's
Report |
01/01/2001 |
| Form
4 (2-Sided Form) |
Report of Compensation
Paid/Suspension Report |
01/01/2011 |
| Form
A (3-Sided Form) |
Instructions
on Fee and Notary Statement
Application for Certificate of Non-Coverage
(2-Sided)
Required Notary Statement |
01/01/2008 |
| Spanish Form A (3-Sided Form) |
Application for Certificate of Non-Coverage
(2-Sided)
Required Notary Statement |
01/01/2008 |
| Form
C (2-Sided Form) |
Claim for Compensation |
06/16/2014 |
| Spanish Form
C (2-Sided Form) |
Claim for Compensation |
08/31/2006 |
| Form
D (2-Sided Form) |
Death/PTD Acceptance/Update |
01/01/2001 |
| Form
H (2-Sided Form) |
Health Notice
for Managed Care |
01/01/2001 |
| Form
L (2-Sided Form) |
Lump Sum Request/Respondent's
Position |
01/01/2001 |
| Form
M (2-Sided Form) |
Monthly Medical-Only
Injury Data |
01/01/2001 |
| Form
N (2-Sided Form) |
Notice to Employer/Notice
to Employee |
08/01/2006 |
| Spanish Form
N (2-Sided) |
Notice to Employer/Notice
to Employee |
08/01/2006 |
| Form
O (2-Sided Form) |
Claim Office / Administrator / Underwriter Designation Form |
07/01/2017 |
| Form
P (2-Sided Form) |
Poster of Instructions |
06/16/2014 |
| Spanish Form
P (2-Sided) |
Poster of Instructions |
06/16/2014 |
| Form
R (One-Sided Form) |
Report of Mediation
Conference |
01/01/2001 |
| Form
S (2-Sided Form) |
Supplemental
Report |
01/01/2001 |
| Form
V (2-Sided Form) |
Verification
of PTD |
01/01/2001 |
| Form
W (2-Sided Form) |
Wage Statement |
01/01/2001 |
| Health
and Safety Division forms |
Revised |
| Form
HS-31-A (2-Sided Form) |
APSS/FSR Application |
01/01/2008 |
| Form
HS-31-C (2-Sided Form) |
Accident Prevention
Services Annual Report |
07/01/2010 |
| Form
HS-31-D (2-Sided Form) |
Accident Prevention
Services Worksheet |
07/01/2010 |
| Form
HS-31-E (One-Sided Form) |
List of FSR/APSS |
01/01/2001 |
| Form
HS-32-A (One-Sided Form) |
Hazard Survey
Report |
01/01/2008 |
| Form
HS-32-B (One-Sided Form) |
Health &
Safety Plan Cover Sheet |
01/01/2008 |
| Form
HS-32-C (One-Sided Form) |
Notification
of Potential Data Error |
01/01/2001 |
| Form
HS-36-A (2-Sided Form) |
Voluntary Drug-Free
Workplace Program Application |
07/01/2010 |
| Form
HS-36-B (One-Sided Form) |
Voluntary Drug-Free
Workplace Program Annual Insurance Carrier Report |
01/01/2008 |
| Self-Insurance
Division forms |
Revised |
| Form
SI-1 (4-Sided Form) |
Individual
Self-Insurer Application |
08/01/2006 |
| Form
SI-11 (3-Sided Form) |
Group Self-Insurance
Application |
08/01/2006 |
| Form
SI-12 (3-Sided Form) |
Application
for Membership in a Group |
08/01/2006 |
| Third-Party
Administration form |
Revised |
| Form
TPA (3-Sided Form) |
Third-Party
Administrator Application / Registration |
09/01/2019 |
| Self-Insurance
Division forms |
Revised |
| Form
SI-7 (One-Sided Form) |
Loss Summary
Data Report |
07/01/2006 |
| Form
SI-7-A (One-Sided Form) |
Loss Summary
Data Report - Itemized Listing |
07/01/2006 |
| Form
SI-41 (3-Sided Form) |
Workers' Compensation
Premium Tax Report |
01/01/2001 |
| Form
SI-41-C (One-Sided Form) |
Instructions
for Completing Premium Tax Report |
01/01/2001 |
| Special
Funds Division forms |
Revised |
| Form
SF-1 (One-Sided Form) |
Claimant Information
Update/Change of Address |
01/01/2001 |
| Form
SF-2 (One-Sided Form) |
Guardianship
Affidavit (Court - Appointed, Non-Minor) |
01/01/2001 |
| Form
SF-3 (One-Sided Form) |
Power of Attorney
Notice & Affidavit |
01/01/2001 |
| Form
SF-4 (One-Sided Form) |
Surviving Spouse
Notice & Affidavit |
01/01/2001 |
| Form
SF-5 (2-Sided Form) |
Guardian's
Affidavit - Dependent Child(ren) |
01/01/2001 |
| Form
SF-6 (One-Sided Form) |
Affidavit for
Dependents Other Than Spouse or Child |
01/01/2001 |
| Form
SF-7 (One-Sided Form) |
Certification
of Acceptance |
01/01/2001 |
| Form
SF-8 (One-Sided Form) |
Authorization
for Release of Student Information |
01/01/2001 |
