Board Forms

2019 Forms revisions are now available.

Due to the nature of the change (SSN/BTN removal) on the revision forms we will only accept the new revision form effective December 1, 2018. No previous revisions of these forms will be accepted after November 30th, 2018. Beginning December 1, 2018 outdated forms will be returned.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).

FORM

REVISION
DATE

TITLE

WC-BOR 2019 Bill of Rights
WC-BOR-Sp 2019 Bill of Rights (Espanol)
WC-P1 2006 Panel of Physicians
WC-P1Sp 2006 Panel of Physicians (Espanol)
WC-P3 2006 WC/MCO Panel
WC-P3Sp 2006 WC/MCO Panel (Espanol)
WC-1 2018 Employer's First Report of Injury
WC-2 2019 Notice of Payment or Suspension of Benefits
WC-2a 2019 Notice of Payment or Suspension of Death Benefits
WC-3 2018 Notice to Controvert
WC-4 2018 Case Progress Report
WC-6 2018 Wage Statement
WC-7   Application for Self Insurance
(Packet available through Licensure & Self-Insurance Division (404) 651-7839
WC-10 2013 Notice of Election or Rejection of Workers' Compensation Coverage
WC-11 2018 Standard Coverage Form Group Self-Insurance Fund Members
WC-12 2018 Request for Copy of Board Records
WC-14 2018 Notice of Claim/Request for Hearing/Request for Mediation
WC-14a 2018 Request to Change Information on a Previously Filed Form WC-14
WC-15 2018 Attorney Certification for No-Liability Stipulations
WC-20a 2018 Medical Report
WC-25 2018 Application/Objection for Lump Sum/Advance Payment
WC-26 2018 Consolidated Yearly Report of Medical Only Cases/Indemnity Cases
WC-100 2018 Request for Settlement Mediation
WC-102 2018 Request for Documents to Parties
WC-102b 2018 Notice of Representation
WC-102c 2018 Attorney Leave of Absence
WC-102d 2018 Motion/Objection to Motion
WC-104 2018 Notice to Employee of Medical Release to Return to Work with Restrictions or Limitations
WC-108a 2018 Attorney Fee Approval
WC-108b 2018 Attorney Withdrawal/Lien
WC-121 2018 Notice of Change of TPA/Servicing Agent
WC-131 2018 Application for Permit to Write Insurance
WC-131a 2018 Annual Insurance Update
WC-200a 2018 Change of Physician/Additional Treatment by Consent
WC-200b 2018 Request/Objection for Change of Physician/Additional Treatment
WC-205 2018 Request for Authorization of Treatment or Testing by Authorized Medical Provider
WC-206 2018 Notice of Intent to Become a Party at Interest
WC-207 2018 Authorization and Consent to Release Information
WC-208   Application for Certification of WC/MCO
(Packet available through Managed Care & Rehabilitation Division (404) 656-0849)
WC-226a 2018 Petition for Appointment of Temporary Conservator of Minor(s)
WC-226b 2018 Petition for Appointment of Temporary Conservator of Legally Incapacitated Adult
WC-240 2018 Notice to Employee of Offer of Suitable Employment
WC-240a 2018 Job Analysis
WC-243 2018 Credit
WC-244 2018 Notice of Intent to Become a Party at Interest
WC-262 2018 Wage Documentation of Temporary Partial Disability Payments
WC-PMT 2018 Petition to Show Cause Regarding Medical Treatment/Testing Recommended by Authorized Medical Provider
WC-PMT(b) 2019 Petition to Show Cause Regarding Medical Treatment/Employee’s Failure to Attend Medical Appointment with an Authorized Treating Physician
WC-R1 2018 Request for Rehabilitation
WC-R1CATEE 2018 Employee's Request for Catastrophic Designation
WC-R2 2018 Rehabilitation Transmittal Form
WC-R2a 2018 Individualized Rehabilitation Plan
WC-R3 2018 Request for Rehabilitation Closure
WC-R5 2018 Request for Rehab Conference
Rehab Objection 2018 Rehab Objection
Rehab Release 2018 Catastrophic Rehab Release
Change of Address 2018 Request for Change of Address
Change of Information 2018 Request to Change Information
Subpoena 2018 Subpoena