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Publications and Forms

Workers' Compensation Subpoena Duces Tecum For Deposition (WC-25-C-AI)

A subpoena for a workers compensation case requiring the attendance of an individual—along with specified documents or other evidence—at a deposition.

Workers' Compensation Subpoena For Deposition (WC-25-B-AI)

A subpoena for a workers compensation case requiring the attendance of an individual at a deposition.

Affidavit for Security Release (WC-264)

A sample affidavit for former self-insured employers requesting release of security.

Affidavit for Security Release - Group Trusts (WC-264-G)

A sample affidavit for former self-insured group trusts requesting release of security.

Affidavit of Exemption for Workers' Compensation Insurance (WC-134)

An affidavit that construction industry business owners who are not required to purchase workers’ compensation insurance may use to aid them in obtaining business licenses from some cities and counties.  Note: This form should not be sent to the Division of Workers’ Compensation.

Application for Authority to Self-Insure (WC-81)

The application to be completed by an employer applying to individually self-insure.

Application for Group Self-Insurance (WC-81A)

The application to be completed by a group of employers applying to form a self-insured group trust.

Auditing Procedures for Applicants for Individual Self-Insurance (WC-130-AI)

The safety auditing procedures for those employers applying to individually self-insure.

Authorization for Release of Confidential Information (WC-249-3)

An authorization for release of confidential information that must accompany the Irrevocable Letter of Credit (WC-249).

Bond of Employer Carrying His Own Risk (WC-82B)

A Surety Bond; one of three options available to meet the self-insurance security requirement.

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