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 46 State Forms found

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WCE-1 Application for Worker's Compensation Clearance Certificate (Spanish)

 Formulario del Estado 55718 (3-15)

PROVIDER FEE REQUEST FOR ASSISTANCE

 State Form 52875 R / 11-14

CERTIFICATION FOR WORKER’S COMPENSATION CARRIERS (Calendar Year 2019)

 State Form 12386-b calendar year 2019

SELF-INSURED EMPLOYER CERTIFICATION (Calendar Year 2021)

 State Form 12386 calendar year 2021

CERTIFICATION FOR WORKER’S COMPENSATION CARRIERS (Calendar Year 2017)

 State Form 12386-b calendar year 2017

CERTIFICATION FOR WORKER’S COMPENSATION CARRIERS (Calendar Year 2018)

 State Form 12386-b calendar year 2018

CERTIFICATION FOR WORKER’S COMPENSATION CARRIERS (Calendar Year 2021)

 State Form 12386-b calendar year 2021

SELF-INSURED EMPLOYER CERTIFICATION (Calendar Year 2019)

 State Form 12386 calendar year 2019

CERTIFICATION FOR WORKER’S COMPENSATION CARRIERS (Calendar Year 2022)

 State Form 12386-b Calendar Year 2022

SELF-INSURED EMPLOYER CERTIFICATION (Calendar Year 2022)

 State Form 12386 Calendar year 2022

Summary of Benefits Paid

 State Form TBD (R1 /)

CERTIFICATION FOR WORKER’S COMPENSATION CARRIERS (Calendar Year 2023)

 State Form 12386-b Calendar year 2023

SELF-INSURED EMPLOYER CERTIFICATION (Calendar Year 2024)

 State Form 12386 calendar year 2024

CERTIFICATION FOR WORKER’S COMPENSATION CARRIERS (Calendar Year 2024)

 State Form 12386-b Calendar year 2024

SELF-INSURED EMPLOYER CERTIFICATION (Calendar Year 2025)

 State Form 12386 calendar year 2025
Disclaimer: These forms may not be the most recent version. Indiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.
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