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Publications and Forms

Claim for Compensation for Line of Duty Compensation Benefits (WCLoD-1)

A claim to be filed regarding a payment to the estate of an Air Ambulance Pilot, an Air Ambulance Registered Professional Nurse, an Emergency Medical Technician, a Firefighter, or a Law Enforcement Officer who was killed in the line of duty.

Claimant Authorization to Disclose Worker's Compensation Records (WC-303)

A form, when properly executed, that allows the Division to release or disclose certain information regarding an individual’s workers’ compensation records. 

Claimant Records Release Authorization (MODES-4384)

An authorization for the release of claimant records.

Claimant Request for Appeal of Unemployment Insurance Determination (MODES-4607)

This is the form for claimants to appeal an unemployment insurance determination.

Complaint Intake Questionnaire - Employment Complaints (MCHR-44)

An intake questionnaire regarding discrimination in employment to be completed within 180 days of alleged discrimination.

Complaint Intake Questionnaire - Housing Complaints (MCHR-46)

An intake questionnaire regarding housing complaints.

Complaint Intake Questionnaire - Public Accommodations (MCHR-45)

An intake questionnaire regarding discrimination in public accomodations to be completed within 180 days of alleged discrimination.

Conozca sus Derechos Capacitacion y orientatcion sobre la discriminacion (MCHR-39-S)

Un folleto de la discriminación que abarque la educación y la formación ofrecida por MCHR. 

Contribution and Wage Adjustment Report (MODES-4A)

Employers use the Contribution and Wage Adjustment Report to adjust summary total and wage data previously reported. A separate report is to be used for each quarter to be adjusted and for each separate account number assigned.

Crime Victim Petition for Review to the LIRC (MOIC-2568)

A petition for review by the LIRC of a decision made by a workers compensation administrative law judge.

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