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Publications and Forms

Claim for Compensation (WC-21-A)

A form to be completed by the injured worker or by his or her attorney when making a claim for workers' compensation for injuries occurring on or after January 1, 2014, based upon the revisions to the Workers’ Compensation Law made by Senate Bill 1.

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.

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