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Publications and Forms

Physician's Rehabilitation Information Sheet (WCR-1A)

A form to be completed by the insurance carrier regarding the eligibility of an injured worker for the physical rehabilitation benefit available through the Second Injury Fund.

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

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

Questions and Affidavit Regarding Benefit Sources and Payments - Affidavit Form A (WCT-2)

Questions and affidavit for claimant regarding benefit sources and payments, form A.

Questions and Affidavit Regarding Completeness of Medical Information Submitted - Affidavit Form E (WCT-6)

Questions and affidavit for claimant regarding completeness of medical information submitted, form E.

Questions and Affidavit Regarding Due Diligence in Enforcing the Judgment - Affidavit Form D (WCT-5)

Questions and affidavit for claimant regarding due diligence in enforcing the judgment, form D.

Questions and Affidavit Regarding Lost Income - Affidavit Form B (WCT-3)

Questions and affidavit for claimant regarding lost income, form B.

Questions and Affidavit Regarding Waiver of Final Judgment and Requirement - Affidavit Form C (WCT-4)

Questions and affidavit for claimant regarding waiver of final judgment and requirement, form C.

Report of Serious Injury Referral Form (WCR-6)

A form to be completed by any party to refer a seriously injured worker who may possibly qualify for physical rehabilitation benefits through the Second Injury Fund.

Request by a Health Care Provider for Case Status Information to file a Medical Fee Dispute Application (WC-194)

A form for use by health care provider to determine case status information to file a medical fee dispute application.

Request for Conference (WC-182)

Request to DWC for conference regarding workers’ compensation case.

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