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 Beginning December 1, 2018 outdated forms will be returned.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 |
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 |