Board Forms

2022 Forms revisions are now available.

Beginning October 1, 2022 outdated forms will be returned.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	2022	Bill of Rights
WC-BOR-Sp	2022	Bill of Rights - Spanish (Declaración de Derechos en Español)
WC-P1	2022	Panel of Physicians
WC-P1Sp	2022	Panel of Physicians - Spanish (Panel de Medicas en Español)
WC-P3	2022	WC/MCO Panel
WC-P3Sp	2022	WC/MCO Panel - Spanish (Panel WC/MCO en Español)
WC-1	2021	Employer's First Report of Injury
WC-2	2022	Notice of Payment or Suspension of Benefits
WC-2a	2022	Notice of Payment or Suspension of Death Benefits
WC-3	2021	Notice to Controvert
WC-4	2021	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	2021	Notice of Election or Rejection of Workers' Compensation Coverage
WC-11	2021	Standard Coverage Form Group Self-Insurance Fund Members
WC-12	2022	Request for Copy of Board Records
WC-14	2022	Notice of Claim/Request for Hearing/Request for Mediation
WC-14a	2022	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	2022	Application/Objection for Lump Sum/Advance Payment
WC-26	2021	Consolidated Yearly Report of Medical Only Cases/Indemnity Cases
WC-100	2018	Request for Settlement Mediation
WC-102	2021	Request for Documents to Parties
WC-102b	2018	Notice of Representation
WC-102c	2018	Attorney Leave of Absence
WC-102d	2021	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	2021	Attorney Withdrawal/Lien
WC-121	2021	Notice of Change of TPA/Servicing Agent
WC-131	2021	Application for Permit to Write Insurance
WC-131a	2021	Annual Insurance Update
WC-200a	2021	Change of Physician/Additional Treatment by Consent
WC-200b	2021	Request/Objection for Change of Physician/Additional Treatment
WC-205	2021	Request for Authorization of Treatment or Testing by Authorized Medical Provider
WC-206	2021	Request to Become a Party at Interest
WC-207	2021	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	2021	Petition for Appointment of Temporary Conservator of Legally Incapacitated Adult
WC-240	2021	Notice to Employee of Offer of Suitable Employment
WC-240a	2018	Job Analysis
WC-243	2021	Credit
WC-244	2021	Request to Become a Party at Interest
WC-262	2021	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)	2021	Petition to Show Cause Regarding Medical Treatment/Employee’s Failure to Attend Medical Appointment with an Authorized Treating Physician
WC-R1	2022	Request for Rehabilitation
WC-R1CATEE	2022	Employee's Request for Catastrophic Designation
WC-R2	2022	Rehabilitation Transmittal Form
WC-R2a	2022	Individualized Rehabilitation Plan
WC-R3	2022	Request for Rehabilitation Closure
WC-R5	2021	Request for Rehab Conference
Rehab Objection	2018	Rehab Objection
Rehab Release	2021	Catastrophic Rehab Release
Change of Address	2021	Request for Change of Address
Change of Information	2022	Request to Change Information
Subpoena	2021	Subpoena