WC Library - Word Forms

AttachmentSize
WC001_First_Report_of_Injury.doc68 KB
WC002_General_Admission_Liability.doc123.5 KB
WC003_Notice_One_Time_Change_Physician.doc144.5 KB
WC004_Final_Admission_Liability.doc230.5 KB
WC006_Entry_ of_ Appearance.doc43.5 KB
WC012_Supplemental_Return_to_Work.doc51 KB
WC015_Workers_Claim_for_Compensation.doc89.5 KB
WC018_Dependents_Claim_for_Compensation.doc126 KB
WC030_Designated_Provider_Disclosure.doc92.5 KB
WC034_Request_to_Redact.doc75.5 KB
WC035_App_Indigent_Determination_Transcript.doc63 KB
WC035_IME_App_Indigent_Determination.doc1.11 MB
WC036_Info_IME.doc33 KB
WC036s_Info_IME_Spanish.doc33.5 KB
WC037_Petition_to_Reopen.doc37 KB
WC043_Rejection_of_Coverage.doc290 KB
WC044_Exclusion_Uncompensated_Public_Officials.doc40 KB
WC045_Construction_Coverage_Rejection.doc278.5 KB
WC049_Work_Comp_Poster.doc27.5 KB
WC049s_Work_Comp_Poster_Spanish.doc28.5 KB
WC050_Notice_of_Injury_Poster.doc723.5 KB
WC054_Petition_Objection_Modify_Terminate_Suspend_Comp.doc131 KB
WC062_Request_for_Lump_Sum.docx36.55 KB
WC063_Request_Offset_Liability_SIF.doc31.5 KB
WC070_App_Admission_MMIF.doc33.5 KB
WC073_Settlement_Order.doc188.5 KB
WC074_Notice_of_Contest.doc67.5 KB
WC076_Request_Appointment_IME_Panel.doc45 KB
WC077_Application_for_DIME.doc89.5 KB
WC078_Application_24_Month_DIME.doc79 KB
WC098_Monthly_Summary.doc41.5 KB
WC102_Pro_Se_Settlement_Order.doc110.5 KB
WC103_ Pro_Se_Settlement_Agreement.doc122 KB
WC104_Represented_ Claimant_Settlement.doc123.5 KB
WC105_Settlement_Routing_Sheet.doc90 KB
WC106_First_Report_Transmittal.doc41.5 KB
WC109_Request_for_Certification.doc44 KB
WC112_Payroll_Statement.doc1.62 MB
WC113_Surcharge.doc19.71 KB
WC131_Utilization_Review.doc75 KB
WC132_IME_Examiner_Summary.doc155.5 KB
WC146_Notice_Proposal_IME.doc70 KB
WC151_Fatal_General_Admission.doc45 KB
WC153_Fatal_Final_Admission.doc201.5 KB
WC164_Physicians_Report_of_Injury.docx31.2 KB
WC165_Notice_Failed_IME_Negotiation.doc30 KB
WC168_Change_ Carrier_or_Adjusting_Firm.doc44.5 KB
WC169_EDI_Senders_Transmission.doc72 KB
WC170_EDI_Senders_Trading_Partner.doc68 KB
WC171_EDI_TPA_Location_List.doc37.5 KB
WC172_EDI_Trading_Partner_Insurer_List.doc28 KB
WC174_Workers_Claim_Transmittal.doc27 KB
WC175_EDI_Sender_Acceptance.doc25 KB
WC178_Request_Notification_Followup_IME.doc42.5 KB
WC179_DIME_Physician_Summary_Disclosure.doc48.5 KB
WC180_DIME_Physician_Summary_Disclosure_Claimant.doc41.5 KB
WC181_MBD_Resolution_Intake.doc88 KB
WC188_ATP_Request_Prior_Auth.doc122.5 KB
WC189_Auth_Release_Information.docx16.93 KB
WC190_Auth_Release_Information_Third_Parties.docx18.05 KB
WC191_Voluntary_Abandonment.doc87.5 KB
WCM03_Permanent_Mental_Impaiment.doc187.5 KB
WCM04_Pharmacy_Billing_Statement.doc70.5 KB