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Board Forms

2013 Forms are now available.  You have until October 1st to start using the new forms.  After October 1st,  all other forms received (by the Board) will be returned.

The Board forms are published in PDF for your convenience for printing or downloading a copy to your storage media.  They do not support on-line completion (forms fill-in).  Use of these forms requires Adobe Acrobat Reader.

 

FORM#

TITLE

WC-BOR Bill of Rights
(Revised 2013)
WC-BOR-Sp Bill of Rights (Espanol)
(Revised 2013)
WC-P1 Panel of Physicians
(Revised 2006)
WC-P1Sp Panel of Physicians (Espanol)
(Revised 2006)
WC-P2 Conformed Panel Of Physicians
(Revised 2006)
WC-P2Sp Conformed Panel Of Physicians (Espanol)
(Revised 2006)
WC-P3 WC/MCO Panel
(Revised 2006)
WC-P3Sp WC/MCO Panel (Espanol)
(Revised 2006)
WC-1 Employer's First Report of Injury
(Revised 2011)
WC-2 Notice of Payment or Suspension of Benefits
(Revised 2013)
WC-2a Notice of Payment or Suspension of Death Benefits
(Revised 2013)
WC-3 Notice to Controvert
(Revised 2011)
WC-4 Case Progress Report
(Revised 2011)
WC-6 Wage Statement
(Revised 2011)
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 2013)
WC-11 Standard Coverage Form Group Self-Insurance Fund Members
(Revised 2012)
WC-12 Request for Copy of Board Records
(Revised 2011)
WC-14 Notice of Claim/Request for Hearing/Request for Mediation
(Revised 2011)
WC-14a Request to Change Employee Information on a WC-14
(Revised 2011)
WC-15 Attorney Certification for No-Liability Stipulations
(Revised 2011)
WC-20a Medical Report
(Revised 2011)
WC-25 Application for Lump Sum/Advance Payment
(Revised 2013)
WC-26 Consolidated Yearly Report of Medical Only Cases/Indemnity Cases
(Revised 2012)
WC-100 Request for Settlement Mediation
(Revised 2011)
WC-102 Request for Documents to Parties
(Revised 2011)
WC-102b Notice of Representation
(Revised 2011)
WC-102c Attorney Leave of Absence
(Revised 2011)
WC-102d Motion/Objection to Motion
(Revised 2012)
WC-104 Notice to Employee of Medical Release to Return to Work with Restrictions or Limitations
(Revised 2014)
WC-108a Attorney Fee Approval
(Revised 2011)
WC-108b Attorney Withdrawal/Lien
(Revised 2011)
WC-121 Notice of Change of TPA/Servicing Agent
(Revised 2011)
WC-131 Application for Permit to Write Insurance
(Revised 2011)
WC-131a Annual Insurance Update
(Revised 2011)
WC-200a Change of Physician/Additional Treatment by Consent
(Revised 2011)
WC-200b Request/Objection for Change of Physician/Additional Treatment
(Revised 2011)
WC-205 Request for Authorization of Treatment or Testing by Authorized Medical Provider
(Revised 2013)
WC-206 Notice of Intent to Become a Party at Interest
(Revised 2011)
WC-207 Authorization and Consent to Release Information
(Revised 2011)
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 Conservator of Minor(s)
(Revised 2012)
WC-226b Petition for Appointment of Temporary Conservator of Legally Incapacitated Adult
(Revised 2012)
WC-240 Notice to Employee of Offer of Suitable Employment
(Revised 2011)
WC-240a Job Analysis
(Revised 2011)
WC-243 Credit
(Revised 2011)
WC-244 Notice of Intent to Become a Party at Interest
(Revised 2012)
WC-262 Wage Documentation of Temporary Partial Disability Payments
(Revised 2011)
WC-R1 Request for Rehabilitation
(Revised 2011)
WC-R1CATEE Employee's Request for Catastrophic Designation
(Revised 2011)
WC-R2 Rehabilitation Transmittal Form
(Revised 2011)
WC-R2a Individualized Rehabilitation Plan
(Revised 2011)
WC-R3 Request for Rehabilitation Closure
(Revised 2013)
WC-R5 Request for Rehab Conference
(Revised 2011)
Rehab Objection Rehab Objection
(New 2011)
Rehab Release Catastrophic Rehab Release
(Revised 2011)
Change of Address Request for Change of Address
(Revised 2011)
Subpoena Subpoena
(Revised 2013)