Board Forms

2018 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 Beginning December 1, 2018 outdated forms will be returned.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). Use of these forms requires Adobe Acrobat Reader.

Link	Description
WC-BOR (44.08 KB)	Bill of Rights (Revised 7/2016)
WC-BOR-Sp (49.9 KB)	Bill of Rights (Espanol) (Revised 7/2016)
WC-P1 (16.96 KB)	Panel of Physicians (Revised 7/2006)
WC-P1Sp (16.68 KB)	Panel of Physicians (Espanol) (Revised 7/2006)
WC-P3 (17.62 KB)	WC/MCO Panel (Revised 7/2006)
WC-P3Sp (17.04 KB)	WC/MCO Panel (Espanol) (Revised 7/2006)
WC-1 (130.36 KB)	Employer's First Report of Injury (Revised 12/2018)
WC-2 (155.43 KB)	Notice of Payment or Suspension of Benefits (Revised 12/2018)
WC-2a (122.07 KB)	Notice of Payment or Suspension of Death Benefits (Revised 12/2018)
WC-3 (124.03 KB)	Notice to Controvert (Revised 12/2018)
WC-4 (28.43 KB)	Case Progress Report (Revised 12/2018)
WC-6 (129.08 KB)	Wage Statement (Revised 12/2018)
WC-10 (128.31 KB)	Notice of Election or Rejection of Workers' Compensation Coverage (Revised 5/2013)
WC-11 (111.18 KB)	Standard Coverage Form Group Self-Insurance Fund Members (Revised 12/2018)
WC-12 (102.7 KB)	Request for Copy of Board Records (Revised 12/2018)
WC-14 (127.42 KB)	Notice of Claim/Request for Hearing/Request for Mediation (Revised 12/2018)
WC-14a (107.42 KB)	Request to Change Information on a Previously Filed Form WC-14 (Revised 12/2018)
WC-15 (91.21 KB)	Attorney Certification for No-Liability Stipulations (Revised 12/2018)
WC-20a (111.97 KB)	Medical Report (Revised 12/2018)
WC-25 (128.52 KB)	Application/Objection for Lump Sum/Advance Payment (Revised 12/2018)
WC-26 (175.95 KB)	Consolidated Yearly Report of Medical Only Cases/Indemnity Cases (Revised 12/2018)
WC-100 (106.47 KB)	Request for Settlement Mediation (Revised 12/2018)
WC-102 (107.29 KB)	Request for Documents to Parties (Revised 12/2018)
WC-102b (108.11 KB)	Notice of Representation (Revised 12/2018)
WC-102c (99.12 KB)	Attorney Leave of Absence (Revised 12/2018)
WC-102d (123.59 KB)	Motion/Objection to Motion (Revised 12/2018)
WC-104 (108.92 KB)	Notice to Employee of Medical Release to Return to Work with Restrictions or Limitations (Revised 12/2018)
WC-108a (120.83 KB)	Attorney Fee Approval (Revised 12/2018)
WC-108b (105.51 KB)	Attorney Withdrawal/Lien (Revised 12/2018)
WC-121 (165.01 KB)	Notice of Change of TPA/Servicing Agent (Revised 12/2018)
WC-131 (164.69 KB)	Application for Permit to Write Insurance (Revised 12/2018)
WC-131a (169.33 KB)	Annual Insurance Update (Revised 12/2018)
WC-200a (108.39 KB)	Change of Physician/Additional Treatment by Consent (Revised 12/2018)
WC-200b (114.09 KB)	Request/Objection for Change of Physician/Additional Treatment (Revised 12/2018)
WC-205 (128.56 KB)	Request for Authorization of Treatment or Testing by Authorized Medical Provider (Revised 12/2018)
WC-206 (104.33 KB)	Notice of Intent to Become a Party at Interest (Revised 12/2018)
WC-207 (120.85 KB)	Authorization and Consent to Release Information (Revised 12/2018)
WC-226a (123.24 KB)	Petition for Appointment of Temporary Conservator of Minor(s) (Revised 12/2018)
WC-226b (127.42 KB)	Petition for Appointment of Temporary Conservator of Legally Incapacitated Adult (Revised 12/2018)
WC-240 (105.75 KB)	Notice to Employee of Offer of Suitable Employment (Revised 12/2018)
WC-240a (121.19 KB)	Job Analysis (Revised 12/2018)
WC-243 (107.14 KB)	Credit (Revised 12/2018)
WC-244 (103.75 KB)	Notice of Intent to Become a Party at Interest (Revised 12/2018)
WC-262 (107.16 KB)	Wage Documentation of Temporary Partial Disability Payments (Revised 12/2018)
WC-R1 (115.75 KB)	Request for Rehabilitation (Revised 12/2018)
WC-R1CATEE (127.77 KB)	Employee's Request for Catastrophic Designation (Revised 12/2018)
WC-R2 (113.8 KB)	Rehabilitation Transmittal Form (Revised 12/2018)
WC-R2a (139.13 KB)	Individualized Rehabilitation Plan (Revised 12/2018)
WC-R3 (118.32 KB)	Request for Rehabilitation Closure (Revised 2018)
WC-R5 (99.17 KB)	Request for Rehab Conference (Revised 12/2018)
Rehab Objection (101.55 KB)	Rehab Objection (Revised 12/2018)
Rehab Release (96.37 KB)	Catastrophic Rehab Release (Revised 12/2018)
Change of Address (115.79 KB)	Request for Change of Address (Revised 12/2018)
Change of Information (107.5 KB)	Request to Change Information (Revised 12/2018)
Petition for Medical Treatment (130.16 KB)	Petition for Medical Treatment (Revised 12/2018)
Subpoena (2.15 MB)	Subpoena (Revised 12/2018)
Board Form Policy
Reasons Forms Are ReJected
Summary of 2018 Form Changes

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