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 55 State Forms found

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EMPLOYEE’S STATEMENT OF EMPLOYMENT STATUS

53WC (12/2000)

Employer's First Report of Injury

 8WC (07/2019)

Employer's Supplemental Report of Injury

 13 WCA (3/2014)

NOTICE OF ACCIDENTAL INJURY OR OCCUPATIONAL DISEASE

 8aWCA (7/2014)

Annual Financial Statement

 WCSI-11 (3/1975)

APPLICATION for CERTIFICATE of AUTHORITY

 WC-TPA-COA (Revised 06/2019)

DISCONTINUED BY STATE, NO REPLACEMENT - APPLICATION FOR REIMBURSEMENT OF PAID ADJUSTED TOTAL DISABILITY BENEFITS FROM SPECIAL FUND FOR ACTIVE CASES

 9WCA-2 - DEACTIVATED 9/2015

APPLICATION FOR REIMBURSEMENT OF PAID COMBINED EARNINGS DIFFERENTIAL FROM SPECIAL FUND FOR SECOND INJURIES

 9WCA-3 (9/2015)

APPLICATION FOR THE USE OF THE SECOND INJURY FUND

 Form No. WCSIF-I (9-2015)

AUTHORIZATION FOR COMPENSATION FOR DEATH

 14 WCA (10/2001)

AUTHORIZATION to Permit Witness at Medical Examination

 38 WCA 9/2015

BIOGRAPHICAL AFFIDAVIT

WC- TPA- BA (3/2019)

CERTIFICATE OF INSURANCE

 WCSI-4 (1/1992)

ENDORSEMENT

 WCSI-5 (4/1996)

GENERAL PURPOSE RIDER

 WCSI-2A (8/30/94)
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