Board Forms

FORM#

TITLE

Bill of Rights
Must be printed and posted on legal size (8½ x 14) pink paper
(Revised 2007)

Bill of Rights (Espanol)
Must be printed and posted on legal size (8½ x 14) pink paper
(Revised 2007)

WC-P1

Panel of Physicians
Must be printed and posted on legal size (8½ x 14) pink paper
(Revised 2006)

WC-P1Sp

Panel of Physicians (Espanol)
Must be printed and posted on legal size (8½ x 14) pink paper
(Revised 2006)

WC-P2

Conformed Panel Of Physicians
Must be printed and posted on legal size (8½ x 14) pink paper
(Revised 2006)

WC-P2Sp

Conformed Panel Of Physicians (Espanol)
Must be printed and posted on legal size (8½ x 14) pink paper
(Revised 2006)

WC-P3

WC/MCO Panel
Must be printed and posted on legal size (8½ x 14) pink paper
(Revised 2006)

WC-P3Sp

WC/MCO Panel (Espanol)
Must be printed and posted on legal size (8½ x 14) pink paper
(Revised 2006)

WC-1

Employer's First Report of Injury
(Revised 2007)

WC-2

Notice of Payment or Suspension of Benefits
(Revised 2007)

WC-2a

Notice of Payment or Suspension of Death Benefits
(Revised 2007)

WC-3

Notice to Controvert
(Revised 2007)

WC-4

Case Progress Report
(Revised 2007)

WC-6

Wage Statement
(Revised 2007)

WC-7

Application for Self Insurance
Packet available through Licensure & Quality Assurance Division (404) 656-4893

WC-10

Notice of Election or Rejection of Workers' Compensation Coverage
(Revised 2006)

WC-11

Standard Coverage Form Group Self-Insurance Fund Members
(Revised 2006)

WC-12

Request for Copy of Board Records
(Revised 2007)

WC-14

Notice of Claim/Request for Hearing/Request for Mediation
(Revised 2007)

Request to Amend a Form WC-14
(Revised 2007)

WC-15

Attorney Certification for No-Liability Stipulations
(Revised 2007)

WC-20a

Medical Report
(Revised 2007)

WC-25

Application for Lump Sum/Advance Payment
(Revised 2007)

WC-26

Consolidated Yearly Report of Medical Only Cases/Indemnity Cases
(Revised 2006)

WC-100

Request for Settlement Mediation
(Revised 2007)

WC-102

Request for Documents to Parties
(Revised 2007)

WC-102b

Notice of Representation
(Revised 2007)

WC-102c

Attorney Leave of Absence
(Revised 2007)

WC-102d

Motion/Objection to Motion
(Revised 2007)

WC-104

Notice to Employee of Medical Release to Return to Work with Restrictions or Limitations
(Revised 2007)

WC-108a

Attorney Fee Approval
(Revised 2007)

WC-108b

Attorney Withdrawal/Lien
(Revised 2007)

WC-121

Notice of Use of Servicing Agent
(Revised 2006)

Permit to Write Insurance
(New 2006)

Permit to Write Insurance Update
(New 2006)

WC-200a

Change of Physician/Additional Treatment by Consent
(Revised 2007)

WC-200b

Request/Objection for Change of Physician/Additional Treatment
(Revised 2007)

WC-205

Request for Authorization of Treatment or Testing by Authorized Medical Provider
(Revised 2007)

WC-206

Notice of Intent to Become a Party at Interest
(Revised 2007)

WC-207

Authorization and Consent to Release Information
(Revised 2007)

WC-208

Application for Certification of WC/MCO
Packet available through Managed Care & Catastrophic Disability Division (404) 656-0849

WC-226a

Petition for Appointment of Temporary Guardianship of Minor(s)
(Revised 2007)

WC-226b

Petition for Appointment of Temporary Guardianship of Legally Incapacitated Adult
(Revised 2007)

WC-240

Notice to Employee of Offer of Suitable Employment
(Revised 2007)

WC-240a

Job Analysis
(Revised 2007)

WC-243

Credit
(Revised 2007)

WC-244

Notice of Intent to Become a Party of Interest
(Revised 2007)

Wage Documentation of Temporary Partial Disability Payments
(Revised 2007)

WC-R1

Request for Rehabilitation
(Revised 2007)

WC-R1CATEE

Employee's Request for Catastrophic Designation
(Revised 2007)

WC-R2

Rehabilitation Transmittal Form
(Revised 2007)

WC-R2a

Individualized Rehabilitation Plan
(Revised 2007)

Request for Rehabilitation Closure
(Revised 2007)

Request for Rehab Conference
(Revised 2007)

Catastrophic Rehab Release
(New 2007)

Request for Change of Address
(Revised 2007)

Subpoena
(Revised 2007)