Workers Compensation Forms and Templates

This document is used in California for submitting stipulations along with a request for an award in a workers' compensation case.

This Form is used for dependents to notify the Administrative Law Judge and their employer about a claim in Connecticut.

This Form is used for reporting a supervisor's statement as part of the workers' compensation investigation in Missouri.

This document is used for requesting an early return to work on a temporary modified duty assignment in the state of Missouri.

This form is used for reporting employee injuries in the state of Missouri for the purpose of filing a workers' compensation claim.

This form is used for authorizing the release of medical records related to a workers' compensation claim in the state of Missouri.

This form is used to apply for an advance payment in the state of Michigan.

This form is used for recording and charting amputations in Michigan. It helps to keep track of amputation cases for legal and medical purposes.

This form is used for carrier's explanation of benefits in Michigan.

This Form is used for healthcare providers to request a reconsideration of a denied claim in the state of Michigan.

This Form is used for filing a claim or cross-claim for review in Michigan. It is used to initiate a legal process for review of a decision made by an administrative agency or court.

This form is used for redeeming abandoned property in Michigan. It allows individuals or organizations to request the release of their abandoned property held by the state.

This form is used for claiming a redemption from multiple insurance carriers in Michigan.

This form is used for authorizing the disclosure of confidential workers' compensation information in Michigan.

This form is used for applying for workers' disability compensation as a group self-insurer in Michigan.

This Form is used for applying as a workers' compensation agency service company in Michigan.

This Form is used for reporting on rehabilitation in the state of Michigan. It is used to gather information about the progress and outcomes of rehabilitation programs.

This form is used for reporting third-party liability in cases of concurrent employment in Connecticut. It is used to provide information on any potential liability of a third party in a workers' compensation claim.

This document is used for reporting absences from work due to occupational injuries or illnesses.

This Form is used for collecting information from workers who are making a workers' compensation claim in Illinois.

This Form is used for employers in Illinois to complete a questionnaire related to worker's compensation.

This Form is used for filing a complaint related to prevailing wage violations in the state of Illinois.

This form is used by employers in Indiana to apply for permission to carry risk without insurance. It is required for employers who want to self-insure their workers' compensation coverage.

This document is used for reporting accidents that occur in the workplace and for individuals participating in Work Release/Owi programs in Iowa. It provides details about the accident, including the location, date, and a description of the incident.

This form is used for workers' compensation self-insured groups in Kentucky to elect safekeeping of securities.

This form is used for trustees to confirm the receipt of workers' compensation self-insured group quarterly financial statements in Kentucky.

This form is used for workers' compensation group security deposit held under safekeeping in Kentucky.

This document is used for the initial application for a Certificate of Filing as a Workers' Compensation Self-insured Group in Kentucky. It is necessary for groups wishing to provide self-insurance for workers' compensation in the state.

This Form is used for partners in Maryland to determine their status as a covered employee.

This form is used for obtaining authorization from a worker's compensation claimant in Missouri to disclose their worker's compensation records.

This form is used for claiming compensation for line of duty compensation benefits in the state of Missouri when a worker's death occurred on or after August 28, 2018.

This form is used for reporting subsequent incidents related to workers' compensation in the state of Montana.

This form is used for employees in Nevada to report their initial treatment and make a claim for compensation related to a work-related injury or illness.