2012 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 2007) |
| WC-BOR-Sp | Bill of Rights (Espanol) (Revised 2007) |
| 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 2011) |
| WC-2a | Notice of Payment or Suspension of Death Benefits (Revised 2011) |
| 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 2011) |
| 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 2011) |
| 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 2011) |
| 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 2011) |
| 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) |
Related Files
| Attachment | Size |
|---|---|
 Summary of 2012 Form Changes | 61.38 KB |
| Reasons Forms Are Rejected | 13.09 KB |