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 73 State Forms found

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Transitional Employment Agreement (SAWC)

 No Form Number 02/12

Employer’s Report of Wages (Encova)

 WC-5244 06-20

First Fill Information (Encova)

 No Form Number 2018

ENCOVA INSURANCE INJURY KIT

 No Form Number 08-20

Medical Records Release (Encova)

 WC-5253 06-20

Return-to-Work Notice (Encova)

 WC-5247 06-20

WORKERS’ COMPENSATION TEMPORARY TOTAL DISABILITY BENEFITS OR SICK LEAVE BENEFITS - ELECTION OF OPTION

 DOP-P7 November 1, 2005

Diagnosis Update (Encova)

 WC-5230 06-20

REQUEST FOR FILE RECORD COPIES

 No Form Number 08/09/2024

REQUEST FOR X-RAYS

 No Form Number 07/31/2024

Notice of Election or Rejection of Workers’ Compensation Coverage

 WVWC-RF01 08/10

Self-Insurance 2018 Claim Data Template (Claim Data as of 12/31/2018)

 No Form Number 12/31/2018

INITIAL NOTICE UNDER W. VA. CODE 23-4-10(f) TO RECIPIENTS OF 104-WEEK AWARD PAID IN MONTHLY PAYMENTS

 No Form Number 10/1/10

NOTICE UNDER W. VA. CODE 23-4-10(f) TO RECIPIENTS OF 104-WEEK AWARD PAID IN A LUMP SUM

 No Form Number 10/1/10

SECOND NOTICE UNDER W. VA. CODE 23-4-10(f) TO RECIPIENTS OF 104-WEEK AWARD PAID IN MONTHLY PAYMENTS

 No Form Number 10/1/10
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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