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Publications and Forms

Electronic Partnering/Confidentiality Agreement (FROI) (WC-250)

A form to be completed by the employer/insurer regarding the electronic filing of First Reports of Injury.

Electronic Partnering/Confidentiality Agreement (Second Injury Fund Surcharge) (WC-276)

A form to be completed by the employer/insurer regarding the electronic filing of the quarterly Second Injury Fund Surcharge Report Forms.

Entry of Appearance (WC-200)

A form for an attorney to enter his or her appearance in a workers' compensation medical fee dispute.

Entry of Appearance (WC-235)

A form for an attorney to make an entry of appearance in a workers' compensation case.

Group Trust New Member Application Checklist (WC-269)

The checklist of required items and information that must accompany the Application for Membership (WC-81B).

Health Care Provider's Response to Request for Award on Undisputed Facts in Regard to Application for Direct Payment (WC-202)

A health care provider’s response to a request for an award on undisputed facts in regard to an application for direct payment medical fee dispute.

Individual Self Insured Employer Information Sheet (WC-131)

Current contact information to be submitted by self-insured employers on an annual basis and as needed.

Motion for Leave to Withdraw (WC-236)

A motion to withdraw an attorney in regards to a workers' compensation case.

Noncompliance Referral Form (WC-258)

Complete the form to report a business for not carrying workers' compensation insurance.

Proposed Rates for Group Trust Self-Insurance (WC-127)

A form to submit proposed rates for a self-insured group trust.

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