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Publications and Forms

Certificate to Employ a Child 14 or 15 Years of Age During Non-School Term (LS-68)

Certificate to employ a child age 14 or 15 during summer months. 

Certificate to Employ a Child 14 or 15 Years of Age During School Term (LS-67)

Certificate to employ a child age 14 or 15 during school months.

Claim for Compensation (WC-21)

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 prior to January 1, 2014.

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-1A)

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 before August 28, 2017.

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.

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