A poster containing information about payroll records to be displayed in workplace.

A form to be completed by physician examining a workers compensation eye injury.


The Division uses the Quarterly Wage Report Continuation Sheet to allow reporting of additional employees when there are more employees than will fit on the Quarterly Contribution and Wage Report (MODES-4). This form MODES-10B should be attached to the MODES-4.


Instructions for completing the application, affidavit and waiver of workers compensation benefits.


Information regarding employees who wish to be exempt from workers' compensation law because of religious reasons.


This form allows employees to provide proper written notification to their employer when a workplace injury/occupational disease occurs.


The form to be completed by an employee who is requesting a rescission from a previously received religious exemption.


A self-evaluation questionnaire to be completed by an unemployed claimant.


A sample of by-laws that may be used as a reference when forming a new group trust.


Certification procedures for a self-insured group trust’s safety program.