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Publications and Forms

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

A claim to be filed regarding a payment to the estate of air ambulance pilots, air ambulance registered professional nurses, emergency medical technicians, firefighters, law enforcement officers, and volunteer firefighters who were killed in the line of duty between August 28, 2017 and before August 28, 2018. 

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

A claim to be filed regarding a payment to the estate of air ambulance pilots, air ambulance registered professional nurses, emergency medical technicians, firefighters, law enforcement officers, volunteer firefighters, air ambulance registered respiratory therapists, flight crew members, and public safety officers who were killed in the line of duty on or after August 28, 2018.

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. 

Construction Data Sheet (LS-77)

Analyzing 2018 workplace injuries in the Construction sector.

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