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2007 Workers Compensation Board Forms


Form WC-1. Employer’s First Report of Injury

Form WC-2. Notice of Payment or Suspension of Benefits

Form WC-2A. Notice of Payment or Suspension of Death Benefits

Form WC-3. Notice to Controvert

Form WC-6. Wage Statement

Form WC-10. Notice to Elect or Reject Coverage

Form WC-11. Standard Coverage Form

Form WC-12. Request for Copy of Board Records

Form WC-14. Notice of Claim/Request for Hearing or Mediation

Form WC-14A. Request to Change Information on a Previously Filed Form WC-14

Form WC-15. Attorney Certification for No-Liability Stipulated Settlements

Form WC-24. Enforcement Division Request for Board Intervention

Form WC-25. Application for Lump Sum/Advance Payment

Form WC-26. Consolidated Yearly Report of Medical Only Claims and Annual Payments on Indemnity Claims

Form WC-100. Request for Settlement Mediation

Form WC-102. Request for Documents from Parties

Form WC-102B. Notice of Representation by an attorney for an employer, insurer, or party-at-interest

Form WC-102C. Attorney Leave of Absence

Form WC-102D. Motion/Objection to Motion

Form WC-104. Notice to Employee of Medical Release to Return to Work with Restrictions or Limitations

Form WC-108a. Attorney Fee Approval

Form WC-108b. Attorney Withdrawal/Attorney Fee Lien

Form WC-121. Change of TPA Claims Office/Servicing Agent

Form WC-131. Permit to Write Insurance

Form WC-131(a). Permit to Write Insurance Update

Form WC-200a. Change of Physician/Additional Treatment by Consent

Form WC-200b. Request/Objection for Change of Physician/Additional Treatment

Form WC-205. Request for Authorization of Treatment or Testing by Authorized Medical Provider

Form WC-206. Reimbursement Request of Group Health Insurance Carrier/Healthcare Provider

Form WC-207. Authorization and Consent to Release Information

Form WC-208a. Application for certification of WC/MCO

Form WC-226(a). Petition for Appointment of Temporary Guardianship of Minor

Form WC-226(b). Petition for Appointment of Temporary Guardianship of Legally Incapacitated Adult

Form WC-240. Notice to Employee of Offer of Suitable Employment

Form WC-244. Reimbursement Request of Group Insurance Carrier/Disability Benefits Provider

Form WC-262. Payment of Temporary Partial Disability Income Benefits

Form WC-R1. Request for Rehabilitation

Form WC-R1CATEE. Employee Request for Catastrophic Designation
Board Rule 61(b)(43)

Form WC-R2. Rehabilitation Transmittal Report

Form WC-R2A. Individualized Rehabilitation Plan

Form WC-R3. Request for Rehabilitation Closure

Form WC-R5. Request for Rehabilitation Conference

Form WC-P1. Panel of Physicians

Form WC-P2. Conformed Panel of Physicians

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Seth Bader
(678) 562-5595