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986 Forms found in Workers Compensation — Page 1 of 20
TitleState Last Updated
Original Notice And Petition And Order For Partial Commutation IowaAugust 27, 2015
Original Notice And Petition And Order For Commutation Of All Remaining Benefits Of 10 Weeks Or More IowaAugust 27, 2015
Corporate Officer Exclusion From Workers Compensation Or Employers Liability Coverage IowaAugust 27, 2015
Contingent Settlement IowaAugust 27, 2015
Coverage Election By Sole Proprietor Or Single Member LLC ConnecticutAugust 27, 2015
Coverage Election By Employees Who Are Members Of Partnership ConnecticutAugust 27, 2015
Coverage Election By Employee Who Is An Officer Or Member ConnecticutAugust 27, 2015
Compromise Settlement IowaAugust 24, 2015
Combination Settlement IowaAugust 24, 2015
Charge Account Application IowaAugust 24, 2015
Agreement For Settlement IowaAugust 24, 2015
Certificate Authorizing Release Of Benefit Information MaineAugust 18, 2015
Application For Predetermination Of Independent Contractor Status (Rebuttable Conclusive Presumption) MaineAugust 18, 2015
Authorization To Disclose Release And Use Protected Health Information (HIPAA Compliant) UtahAugust 4, 2015
Application For Hearing UtahAugust 4, 2015
Application For Hearing (Occupational Disease Claim) UtahAugust 4, 2015
Medical Treatment Provider List UtahAugust 4, 2015
Corporate Officer Exclusion From Workers Compensation Or Employers Liability Coverage UtahAugust 4, 2015
Application For Hearing Medical Care Provider UtahAugust 4, 2015
Medical Records Copies UtahAugust 3, 2015
Employees Notification Of Intent To Leave Locality Or State And To Change Doctor Or Hospital UtahAugust 3, 2015
Initial Statement Of Insurance Carrier Or Self Insurer With Respect To Payment Of Benefits UtahAugust 3, 2015
Release To Return To Work UtahJuly 31, 2015
Restorative Services Authorization Denial (Spine) UtahJuly 29, 2015
Physicians Initial Report Of Work Injury Or Occupational Disease UtahJuly 29, 2015
Permanent Partial Disability Agreement UtahJuly 29, 2015
Employers First Report Of Injury Or Illness UtahJuly 29, 2015
Employee Notification Of Denial Or Partial Denial Of Claim UtahJuly 29, 2015
Renewal Application For License To Appear On Behalf Of Or Represent Carriers And-Or Self-Insurers New YorkJuly 28, 2015
Initial Application For License To Appear On Behalf Of Or Represent Carriers And-Or Self-Insurers New YorkJuly 28, 2015
Doctors Initial Report New YorkJuly 28, 2015
ADR Program Final Disposition Of Claim New YorkJuly 28, 2015
Report Of Work-Related Injury Or Occupational Disease New YorkJuly 28, 2015
Disagreement With Proposed Vocational Rehabilitation Plan MarylandJuly 23, 2015
Authorization For Release Of Medical Information MarylandJuly 9, 2015
Employee Claim New YorkJuly 7, 2015
Beneficiary Claim For Death Benefits TexasJune 26, 2015
Employer Notice Of No Coverage Or Termination Of Coverage TexasJune 26, 2015
Initial Application By Employee Of Licensee Under Section 50 3-b Or 50 3-d To Appear Before WCB New YorkMay 4, 2015
Stockholder Of Corporation Applying For License To Represent Self-Insurers New YorkMay 4, 2015
Voluntary Agreement ConnecticutApril 17, 2015
Subpoena Or Subpoena Duces Tecum Or Subpeona Duces Tecum For Medical Record MarylandApril 13, 2015
Statement Of Wage Information MarylandApril 13, 2015
Settlement Worksheet MarylandApril 13, 2015
Request For Transcript MarylandApril 13, 2015
Request For Emergency Hearing MarylandApril 13, 2015
Insurer Request For Change Of Address MarylandApril 13, 2015
Health Providers Request For Decision On Unpaid Medical Bills New YorkMarch 26, 2015
Petition for Benefit Determination TennesseeFebruary 27, 2015
Claim For Medical Services MarylandFebruary 4, 2015