Claims for Compensation

 

 Form

Description

Formats 

Workers' Claim for Compensation 
Form #WC15
(Rev. 03/11)

This form is filed by the injured worker and provides notice to the Division and insurer that workers' compensation benefits are claimed.

 PDF 

 MS Word  

Dependent's Notice and Claim for Compensation 
Form #WC18
(Rev. 04/06)

This form is filed by the dependents of a deceased worker and provides notice to the Division and the insurer that workers' compensation dependent's benefits are claimed.

 PDF 

 MS Word