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Publications and Forms

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.

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.

Request for Award on Undisputed Facts in Regard to Application for Direct Payment (WC-201)

A request by an employer or insurer for an award on undisputed facts in regard to application for a direct payment medical fee dispute.

Request for Certification of Rehabilitation Providers (WCR-8)

A form to be completed by a health care provider requesting certification as a rehabilitation facility.