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 Beginning December 1, 2018 outdated forms will be returned.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	Request 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	Request 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	2020	Subpoena