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941 Forms found in Workers Compensation — Page 1 of 19
TitleState Last Updated
Authorization To Release Industrial Accident Division Records UtahJuly 23, 2014
Carriers Request For Reimbursement Of Compensation Payments Under Section 14(6) (Blue Paper) New YorkJuly 21, 2014
Employers Application For Permission To Carry Risk Without Insurance (For New And Renewal Applicants) IndianaJuly 21, 2014
Notice For Workers Compensation And Occupational Diseases Coverage IndianaJuly 17, 2014
Calculation Of Compensation South DakotaMay 11, 2014
Pre-Hearing Conference Statement New YorkApril 17, 2014
Employers First Report Of Work-Related Injury Or Illness New YorkApril 3, 2014
Cover Sheet-Application For Board Review New YorkMarch 13, 2014
Affidavit For Death Benefits New YorkFebruary 13, 2014
ADR Program Final Disposition Of Claim New YorkFebruary 13, 2014
Accident Prevention Services Annual Report w-Intsructions TexasFebruary 5, 2014
Accident Prevention Services Worksheet TexasFebruary 5, 2014
Workers Compensation Coverage Waiver UtahFebruary 4, 2014
HBA Participation Agreement UtahFebruary 4, 2014
Petition For Reimbursement From The Employers Reinsurance Fund UtahFebruary 4, 2014
Persons With Knowledge List UtahFebruary 4, 2014
URCA Participation Agreement UtahFebruary 4, 2014
UMA Participation Agreement UtahFebruary 4, 2014
UTA Participation Agreement UtahFebruary 4, 2014
Notice Of Filing Application For Hearing For Termination Or Reduction Of Compensation UtahFebruary 4, 2014
Authorization To Disclose Release And Use Protected Health Information (HIPAA Compliant) UtahFebruary 4, 2014
Authorization To Disclose Release And Use Protected Health Information (Adjudication) UtahFebruary 4, 2014
Application For Hearing For Termination Or Reduction Of Compensation UtahFebruary 4, 2014
Application For Hearing Failure Of Diligent Pursuit UtahFebruary 4, 2014
Application For Hearing (Occupational Disease Claim) UtahFebruary 4, 2014
AGC Participation Agreement UtahFebruary 4, 2014
Officer Manager Rejection Of Coverage VirginiaFebruary 4, 2014
Subpoena Duces Tecum Civil Attorney Issued VirginiaFebruary 4, 2014
Contractors Certification Of Workers Compensation Liability VirginiaFebruary 4, 2014
Combination Supplementary And Claim Summary Form AlabamaJanuary 27, 2014
Assessment Report 2012 AlabamaJanuary 27, 2014
Motion For Approval Of Out Of State Health Care Provider New MexicoDecember 19, 2013
Registration Of Participation In World Trade Center Rescue Recovery Clean-Up Operations New YorkDecember 13, 2013
Case Management Closure Instructions TennesseeOctober 31, 2013
Application For Appointment To The Medical Impairment Rating (MIR) Registry TennesseeOctober 31, 2013
WAMO Settlement Agreement - Section 32 WCL New YorkSeptember 19, 2013
Volunteers Notification Of Exec Officer Fire-Ambulance Company-Significant Risk Of HIV New YorkSeptember 19, 2013
Volunteer Firefighters Claim For Benefits New YorkSeptember 19, 2013
Volunteer Ambulance Workers Claim For Benefits New YorkSeptember 19, 2013
Request For Further Action By Carrier-Employer New YorkSeptember 19, 2013
Report Of Work-Related Injury Or Occupational Disease New YorkSeptember 19, 2013
Proof Of Burial And Funeral Expenses By Undertaker New YorkSeptember 19, 2013
Political Subdivisions Report Of Injury To Volunteer Firefighter New YorkSeptember 19, 2013
Notice To Chair Of Carriers Action On Claim For Benefits New YorkSeptember 19, 2013
Notice That Right To Compensation Is Controverted New YorkSeptember 19, 2013
Modification Of Previous Report (ADR Program) New YorkSeptember 18, 2013
Medical Proof Of Change In Condition In Support Of Application For Reopening Of Claim New YorkSeptember 18, 2013
Employers Statement Of Wage Earnings Preceeding The Date Of Accident New YorkSeptember 18, 2013
Employers Report Of Work-Related Injury-Illness New YorkSeptember 18, 2013
Employee Claim New YorkSeptember 18, 2013