Board Forms

2021 Forms revisions are now available.

Beginning October 1, 2021 outdated forms will be returned.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

Download this pdf file. WC-BOR 2019 Bill of Rights
Download this pdf file. WC-BOR-Sp 2019 Bill of Rights (Espanol)
Download this pdf file. WC-P1 2021 Panel of Physicians
Download this pdf file. WC-P1Sp 2021 Panel of Physicians (Espanol)
Download this pdf file. WC-P3 2021 WC/MCO Panel
Download this pdf file. WC-P3Sp 2021 WC/MCO Panel (Espanol)
Download this pdf file. WC-1 2021 Employer's First Report of Injury
Download this pdf file. WC-2 2021 Notice of Payment or Suspension of Benefits
Download this pdf file. WC-2a 2021 Notice of Payment or Suspension of Death Benefits
Download this pdf file. WC-3 2021 Notice to Controvert
Download this pdf file. WC-4 2021 Case Progress Report
Download this pdf file. WC-6 2018 Wage Statement
WC-7   Application for Self Insurance
(Packet available through Licensure & Self-Insurance Division (404) 651-7839
Download this pdf file. WC-10 2021 Notice of Election or Rejection of Workers' Compensation Coverage
Download this pdf file. WC-11 2021 Standard Coverage Form Group Self-Insurance Fund Members
Download this pdf file. WC-12 2018 Request for Copy of Board Records
Download this pdf file. WC-14 2021 Notice of Claim/Request for Hearing/Request for Mediation
Download this pdf file. WC-14a 2018 Request to Change Information on a Previously Filed Form WC-14
Download this pdf file. WC-15 2018 Attorney Certification for No-Liability Stipulations
Download this pdf file. WC-20a 2018 Medical Report
Download this pdf file. WC-25 2021 Application/Objection for Lump Sum/Advance Payment
Download this pdf file. WC-26 2021 Consolidated Yearly Report of Medical Only Cases/Indemnity Cases
Download this pdf file. WC-100 2018 Request for Settlement Mediation
Download this pdf file. WC-102 2021 Request for Documents to Parties
Download this pdf file. WC-102b 2018 Notice of Representation
Download this pdf file. WC-102c 2018 Attorney Leave of Absence
Download this pdf file. WC-102d 2021 Motion/Objection to Motion
Download this pdf file. WC-104 2018 Notice to Employee of Medical Release to Return to Work with Restrictions or Limitations
Download this pdf file. WC-108a 2018 Attorney Fee Approval
Download this pdf file. WC-108b 2021 Attorney Withdrawal/Lien
Download this pdf file. WC-121 2021 Notice of Change of TPA/Servicing Agent
Download this pdf file. WC-131 2021 Application for Permit to Write Insurance
Download this pdf file. WC-131a 2021 Annual Insurance Update
Download this pdf file. WC-200a 2021 Change of Physician/Additional Treatment by Consent
Download this pdf file. WC-200b 2021 Request/Objection for Change of Physician/Additional Treatment
Download this pdf file. WC-205 2021 Request for Authorization of Treatment or Testing by Authorized Medical Provider
Download this pdf file. WC-206 2021 Request to Become a Party at Interest
Download this pdf file. 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)
Download this pdf file. WC-226a 2018 Petition for Appointment of Temporary Conservator of Minor(s)
Download this pdf file. WC-226b 2021 Petition for Appointment of Temporary Conservator of Legally Incapacitated Adult
Download this pdf file. WC-240 2021 Notice to Employee of Offer of Suitable Employment
Download this pdf file. WC-240a 2018 Job Analysis
Download this pdf file. WC-243 2021 Credit
Download this pdf file. WC-244 2021 Request to Become a Party at Interest
Download this pdf file. WC-262 2021 Wage Documentation of Temporary Partial Disability Payments
Download this pdf file. WC-PMT 2018 Petition to Show Cause Regarding Medical Treatment/Testing Recommended by Authorized Medical Provider
Download this pdf file. WC-PMT(b) 2021 Petition to Show Cause Regarding Medical Treatment/Employee’s Failure to Attend Medical Appointment with an Authorized Treating Physician
Download this pdf file. WC-R1 2021 Request for Rehabilitation
Download this pdf file. WC-R1CATEE 2021 Employee's Request for Catastrophic Designation
Download this pdf file. WC-R2 2021 Rehabilitation Transmittal Form
Download this pdf file. WC-R2a 2021 Individualized Rehabilitation Plan
Download this pdf file. WC-R3 2021 Request for Rehabilitation Closure
Download this pdf file. WC-R5 2021 Request for Rehab Conference
Download this pdf file. Rehab Objection 2018 Rehab Objection
Download this pdf file. Rehab Release 2021 Catastrophic Rehab Release
Download this pdf file. Change of Address 2021 Request for Change of Address
Download this pdf file. Change of Information 2018 Request to Change Information
Download this pdf file. Subpoena 2021 Subpoena