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Publications and Forms

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.

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.

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