Summary of 2018 Form Changes

FORM CHANGES – EFFECTIVE DECEMBER 1, 2018

The following forms were amended to remove the SSN/BTN box in the header and/or the label for “Address” was changed to “Mailing Address.”

  • WC-1 FIRST REPORT OF INJURY
  • WC-2 NOTICE OF PAYMENT OR SUSPENSION OF BENEFITS
  • WC-2A NOTICE OF PAYMENT OR SUSPENSION OF DEATH BENEFITS
  • WC-3 NOTICE TO CONTROVERT
  • WC-4 CASE PROGRESS REPORT
  • WC-6 WAGE STATEMENT
  • WC-12 REQUEST FOR COPY OF BOARD RECORDS
  • WC-14 NOTICE OF CLAIM/REQUEST FOR HEARING/REQUEST FOR MEDIATION
  • WC-14A NOTICE TO AMEND INFORMATION ON A WC-14
  • WC-15 ATTORNEY CERTIFICATION FOR NO-LIABILITY SETTLEMENTS
  • WC-20A MEDICAL REPORT
  • WC-25 REQUEST FOR LUMP SUM OR ADVANCE PAYMENT
  • WC-100 REQUEST FOR SETTLEMENT MEDIATION
  • WC-102 REQUEST FOR DOCUMENTS TO PARTIES
  • WC-102B NOTICE OF REPRESENTATION
  • WC-102D MOTION/OBJECTION TO MOTION
  • WC-104 NOTICE TO EMPLOYEE OF MEDICAL RELEASE TO RETURN TO WORK WITH RESTRICTIONS OR LIMITATIONS
  • WC-108A ATTORNEY FEE APPROVAL
  • WC-108B ATTORNEY WITHDRAWAL/LIEN
  • WC-200A CHANGE OF PHYSICIAN/ADDITIONAL TREATMENT BY CONSENT
  • WC-200B MOTION/OBJECTION FOR CHANGE OF PHYSICIAN/ADDITIONAL TREATMENT
  • WC-205 REQUEST FOR AUTHORIZATION OF TREATMENT OR TESTING BY AUTHORIZED MEDICAL PROVIDER
  • WC-206 NOTICE OF INTENT TO BECOME A PARTY OF INTEREST
  • WC-226A PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR OF MINOR(S)
  • WC-226B PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR OF LEGALLY INCAPACITATED ADULT
  • WC-240 NOTICE TO EMPLOYEE OF OFFER OF SUITABLE EMPLOYMENT
  • WC-240A JOB ANALYSIS
  • WC-243 CREDIT/REDUCTION IN BENEFITS
  • WC-244 NOTICE OF INTENT TO BECOME A PARTY AT INTEREST
  • WC-262 WAGE DOCUMENTATION OF TEMPORARY PARTIAL DISABILITY PAYMENTS
  • WC-R1 REQUEST FOR REHABILITATION
  • WC-R1CATEE EMPLOYEE’S REQUEST FOR CATASTROPHIC DESIGNATION
  • WC-R2 REHABILITATION TRANSMITTAL FORM
  • WC-R2A INDIVIDUALIZED REHABILITATION PLAN
  • WC-R3 REQUEST FOR REHABIILTATION CLOSURE
  • WC-R5 REQUEST FOR REHAB CONFERENCE
  • WC-REHAB OBJECTION
  • WC-CHANGE OF ADDRESS
  • WC-CHANGE OF INFORMATION

Additional changes are noted below.

WC-2 NOTICE OF PAYMENT OR SUSPENSION OR SUSPENSION OF BENEFITS: The format was standardized for the party section (Section A).

WC-2A NOTICE OF PAYMENT OF SUSPENSION OF DEATH BENEFITS: The format was standardized for the party section (Section A).

WC-3 NOTICE TO CONTROVERT: The format was standardized for the party section (Section A).

WC-6 WAGE STATEMENT: The format was standardized for the party section (Section A).

WC-11 STANDARD COVERAGE FORM GROUP SELF-INSURANCE MEMBERS: All label/text with “dba” changed to “DBA.” Removed “and Servicing Agent” from Section C and added city, state and zip code fields.

WC-12 REQUEST FOR COPY OF BOARD RECORDS: Changed the label in Section B from “REQUEST COVERAGE INFORMATION” to “REQUEST CERTIFIED COVERAGE INFORMATION.”

WC-14A REQUEST TO CHANGE INFORMATION ON A PREVIOUSLY FILED FORM WC-14: In the “Add Hearing Issues” section, “DO NOT USE THIS SECTION TO ADD/DELETE PARTIES” was added.

WC-102B – NOTICE OF REPRESENTATION OF ANY PARTY OTHER THAN A CLAIMANT OR AN EMPLOYEE BY AN ATTORNEY: Added “Employee Phone Number” field.

WC-102D – MOTION/OBJECTION TO MOTION: Added SBWC insurer ID number field in claims office section and added phone number field in employer, attorney and claims office section.

WC-104 NOTICE TO EMPLOYEE OF RETURN TO WORK WITH RESTRICTIONS OR LIMITATIONS: Added phone number field in employer, attorney, claims office and signature sections.

WC-108A – ATTORNEY FEE APPROVAL: Added phone number field in Section E.

WC-108B – ATTORNEY WITHDRAWAL/LIEN: Added Section C and changed previous Section C to Section D. In Section A, changed “Client” to “Claimant.”

WC-121 NOTICE OF CHANGE OF TPA/SERVICING AGENT: Multiple format changes.

WC-131A ANNUAL INSURER UPDATE: Multiple label changes.

WC-200B REQUEST/OBJECTION FOR CHANGE OF PHYSICIAN/ADDITIONAL TREATMENT: The format was standardized for the party section (Section A).

WC-243 CREDIT: Changed label in Section C from “Certificate” to “Certificate of Service.”

WC-R1CATEE REQUEST FOR CATASTROPHIC DESIGNATION: Changed “SITF” to “Other Party or SITF.”

WC-R3 REQUEST FOR REHABILITATION CLOSURE: Changed “SITF” to “Other Party or SITF.”

WC-CHANGE OF INFORMATION: Changed second box from “SSN/BTN” to “Birth Date.”