| Title |
Last Updated |
| Non Prejudicial Agreement |
June 12, 2019 |
| Memorandum Of Agreement |
June 12, 2019 |
| Employees Certificate Of Dependency Status |
June 12, 2019 |
| Employees Petition To Review And Or Amend Agreement |
April 8, 2019 |
| Employees Petition For Compensation Benefits |
April 8, 2019 |
| Medical Fee Schedule Order Form |
November 30, 2016 |
| Petition For Compensation Benefits Of Deceased Employee |
November 30, 2016 |
| Workers Compensation Act Summary Poster (English) |
November 30, 2016 |
| Workers Compensation Act Summary Poster (Spanish) |
November 30, 2016 |
| Petition Coversheet |
November 30, 2016 |
| Claim For Trial |
November 30, 2016 |
| Suspension Agreement And Receipt |
November 30, 2016 |
| Wage Transcript |
November 30, 2016 |
| Employers First Report Of Alleged Occupational Injury Disease Or Fatality |
November 30, 2016 |
| Report Of Earnings |
November 30, 2016 |
| Seasonal Wage Statement |
November 30, 2016 |
| Full Time Wage Statement |
November 30, 2016 |
| Coordination Of Retirement Benefits |
November 30, 2016 |
| Employees Objection To Wage Transcript |
November 30, 2016 |
| Mutual Agreement |
March 30, 2016 |
| Attorney Worksheet For Lump Sum Or Structured-Type Settlements |
October 23, 2015 |
| Rescind Notice Of Claim Of Common Law Rights |
April 13, 2015 |
| Physicians Notice Of Release To Work |
April 13, 2015 |
| Notice Of Claim Of Common Law Rights |
April 13, 2015 |
| Request For Permission For Major Surgery |
August 22, 2013 |
| Claim Of Appeal To Appellate Division |
August 22, 2013 |
| Petition For Order Concerning Payment For Medical Services |
January 7, 2009 |
| Employers Petition To Review And Or Amend Agreement Or Decree Concerning Compensation |
January 7, 2009 |
| Attorney Worksheet Settlement For Lump Sum Or Structural Type Payments |
December 2, 2008 |
| Request For Additional Palliative Care |
September 1, 2006 |
| Part Time Wage Statement |
September 1, 2006 |
| Insurance Coverage Certification For Temporary Employment And Employee Leasing Companies |
September 1, 2006 |
| Stipulation |
August 9, 2006 |
| Notification Of Claim Of Compensable Injury |
August 9, 2006 |
| Notice To Employees Regarding Effect Of Endorsement Of Benefit Check |
August 9, 2006 |
| Notice Of Designation Of Independent Contractor |
August 9, 2006 |
| Notice Of Withdrawal Of Designation As Independent Contractor |
August 9, 2006 |
| Original Petition |
April 6, 2005 |
| Election By Exempt Corporate Officer To Become Subject To Workers Compensation |
April 6, 2005 |
| Report Of Specific Payment |
April 6, 2005 |
| Report Of Indemnity Payment |
April 6, 2005 |
| Itemized Statement Of Compensation |
April 6, 2005 |
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