| Title |
Last Updated |
| Semi Annual Report Workers Compensation Premium Tax |
March 15, 2018 |
| Subpoena |
January 23, 2018 |
| Election Of Coverage |
January 4, 2018 |
| Answer To Complaint |
January 4, 2018 |
| Semi Annual Report Workers Compensation Tax Report For Self Insured Employers |
November 30, 2016 |
| Employer Certificate And Request For Claims History |
November 30, 2016 |
| Claimants Request For Personal Workers Compensation Records |
November 30, 2016 |
| Reimbursement Of Health Care Travel Expenses |
November 30, 2016 |
| Employer Certificate And Claims History Release |
November 30, 2016 |
| Response To Petition For Change Of Physician |
November 30, 2016 |
| Disclosure Statement |
November 30, 2016 |
| Response To Motion For Approval Of Disputed Charge |
March 30, 2016 |
| Motion To Present Additional Evidence |
March 30, 2016 |
| Referral Form |
March 30, 2016 |
| First Report Of Injury Or Illness |
March 30, 2016 |
| Motion For Reconsideration |
March 30, 2016 |
| Motion For Approval Of Disputed Charge |
March 30, 2016 |
| Petition For Change Of Physician |
March 30, 2016 |
| Workers Compensation Claims Involving Medical Payments Only And Claims Involving Indemnity Payments Report |
September 4, 2015 |
| Application Workers Compensation Self Insurance |
April 13, 2015 |
| Notice Of Intent To File Workers Compensation Complaint Against Industrial Special Indemnity Fund |
April 13, 2015 |
| Request For Workers Compensation Records |
January 9, 2013 |
| Self Insured Employer Semi Annual Premium Tax Computation |
January 9, 2013 |
| Employer Certificate And Claims History Release |
January 9, 2013 |
| Sexual Assault Examination Program Reimbursement Form |
November 27, 2012 |
| Initial Treatment Plan (Medication Management) |
November 27, 2012 |
| Initial Treatment Plan (Counseling) |
November 27, 2012 |
| Initial Treatment Plan (Chiropractic Care-Massage Therapy-Other) |
November 27, 2012 |
| Family Assistance Application |
November 27, 2012 |
| Application For Compensation |
November 27, 2012 |
| Authorization To Release Claims History |
December 3, 2010 |
| Workers Compensation Complaint And Industrial Special Indemnity Fund |
November 6, 2008 |
| Workers Compensation Complaint |
November 6, 2008 |
| Request For Mediation |
January 3, 2007 |
| Request For Approval Of Disputed Charge |
November 15, 2006 |
| Summary Of Payments Fatal Case |
September 5, 2006 |
| Summary Of Payments Non Fatal Cases |
September 5, 2006 |
| Notice Of Claim Status |
September 5, 2006 |
| Employers Supplemental Report |
September 5, 2006 |
| Declaration Of Exemption |
September 5, 2006 |
| Certificate Of Verification Of Workers Compensation Insurance |
September 5, 2006 |
| Request For Mediation |
September 5, 2006 |
| Supplemental Application Subsidiary Coverage For Workers Compensation Self Insurers |
July 27, 2005 |
| Report Of Outstanding Awards For Fatal Permanent Partial Impairment And Permanent Total Disability Claims |
July 27, 2005 |
| Application For Waiver And Affidavit In Support |
July 27, 2005 |
| Report Of Litigation Expenses (Employer-Surety-ISIF-Self Insureds) |
July 27, 2005 |
| Report Of Litigation Expenses (Claimants Attorney) |
July 27, 2005 |
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