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West Virginia Forms

73 State Forms found

name	number	revision	print or send online
Employees' and Physicians' Report of Occupational Injury or Disease	Form OIC-WC-1	No Form/Rev Date
Employee's and Physician's Report of Occupational Hearing Loss	OIC-WC-1HL	No Form/Rev Date
Physician's Report of Occupational Pneumoconiosis (Encova)	WC-5236	06-20
Application for Verification of Statutory Exemption from WV Workers’ Compensation Coverage	Exempt App	Rev. 10/2018
Application for Fatal Dependents' Benefits	OIC-WC-201	Rev 8/2020
Application for 104 Weeks Depedents' Benefits	OIC-WC-202	Rev. 1/11
Attending Physician Benefits Form	No Form Number	No Form/Rev Date
Burial Insurance Benefit Assignment Form	No Form Number	No Form/Rev Date
CARRIER'S REQUEST FOR OCCUPATIONAL LUNG CENTER EXAMINATION	No Form Number	(Rev. 7/2021)
Controlled Substance Form	No Form Number	No Form/Rev Date
Credentialing Form	No Form Number	5/11
Diagnosis Update	No Form Number	No Form/Rev Date
Employees' Report of Occupational Pneumoconiosis	Form OIC-WC-1OP	No Form/Rev Date
Employer's Report of Occupational Injury or Disease - EDI	OIC-WC-2	No Form/Rev Date
INSURANCE COMPANY FRAUD CONTACT FORM	No Form Number	No Form/Rev Date

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Disclaimer: These forms may not be the most recent version. West Virginia 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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