| Title | State |
Last Updated |
| Average Weekly Wage Worksheet |
Colorado | April 13, 2015 |
| Application For Indigent Determination |
Colorado | April 13, 2015 |
| Application For NH Vocational Rehabilitation Provider Certification |
New Hampshire | April 13, 2015 |
| Notice Of Election Or Rejection Of Workers Compensation Coverage |
Georgia | April 13, 2015 |
| Order Approving Settlement With Dismissal Under NJSA 34 15-20 |
New Jersey | April 13, 2015 |
| First Report Of Alleged Occupational Injury Or Illness |
Nebraska | April 13, 2015 |
| Provider Accounts Change Form For Crime Victims Compensation |
Washington | April 13, 2015 |
| Amended Settlement Agreement And Release |
Ohio | March 4, 2015 |
| Agreement As To Compensation For Permanent Partial Disability |
Ohio | March 4, 2015 |
| Request For Cancellation |
Ohio | February 25, 2015 |
| State Fund Employers Agreement To Accept Claim Assignment |
Ohio | February 25, 2015 |
| Self-Insured Employers Certification Of Assignment After Initial Allowance |
Ohio | February 25, 2015 |
| Self-Assessment For 10-Step Business Plan For Safety |
Ohio | February 25, 2015 |
| Request To Correct Employer And Or Policy Number Assignment |
Ohio | February 25, 2015 |
| Lump Sum Settlement (LSS) |
Ohio | February 25, 2015 |
| Filing Of An Allegation Against A Self Insured Employer |
Ohio | February 25, 2015 |
| Application For Ohio Workers Compensation Coverage |
Ohio | February 25, 2015 |
| Application For Drug Safety Program |
Ohio | February 25, 2015 |
| Injured Worker Reimbursement Rates For Travel Expense |
Ohio | February 25, 2015 |
| Injured Worker Authorized Representative |
Ohio | February 25, 2015 |
| Outpatient Medication Invoice |
Ohio | February 25, 2015 |
| Application For Wage Loss Compensation |
Ohio | February 25, 2015 |
| Notice Of Change Of Workers Compensation Disability Status |
Pennsylvania | January 30, 2015 |
| Employees Claim Petition |
New Jersey | January 13, 2015 |
| Public Employers Election To Self-Insure |
Illinois | December 22, 2014 |
| Tort Victims Compensation Claim |
Missouri | December 16, 2014 |
| Request For Dismissal Of Application For Payment of Additional Reimbursements |
Missouri | December 16, 2014 |
| Chart 1-Permanent Partial Disability Schedule |
Missouri | December 16, 2014 |
| Temporary Or Permanent Disability Benefits For Job Related Injuries |
Wisconsin | November 19, 2014 |
| Interested Party Update Request |
Pennsylvania | November 13, 2014 |
| Annual Report Of Inventory For Claims Reported During Calendar Year |
California | October 1, 2014 |
| Workers Compensation Payroll And Assessment Quarterly Report Retrospective Rating Plan |
Oregon | October 1, 2014 |
| Workers Compensation Payroll And Assessment Quarterly Report Retrospective Rating Plan (5-12) |
Oregon | October 1, 2014 |
| Workers Compensation Payroll And Assessment Quarterly Report Normal Plan |
Oregon | October 1, 2014 |
| Workers Compensation Payroll And Assessment Quarterly Report Normal Plan (5-12) |
Oregon | October 1, 2014 |
| Self Insurer Report Of Losses Non Experience Rating Period |
Oregon | October 1, 2014 |
| Self Insurer Report Of Losses Experience Rating Period |
Oregon | October 1, 2014 |
| Group Self Insured Indemnity Agreement |
Oregon | October 1, 2014 |
| Exemption Provision Waiver |
Oregon | October 1, 2014 |
| Endorsement To Self Insured Group Application |
Oregon | October 1, 2014 |
| Claims Reserved In Excess Of Self-Insured Retention |
Oregon | October 1, 2014 |
| Preferred Worker Program Quarterly Claim Cost Reimbursement Request |
Oregon | October 1, 2014 |
| Notice Of Intent To Form A Managed Care Organization |
Oregon | October 1, 2014 |
| Request Ror Reimbursement Of Expenses |
Oregon | October 1, 2014 |
| Medical Billing Data EDI Trading Partner Profile |
Oregon | October 1, 2014 |
| IME Observer Form |
Oregon | October 1, 2014 |
| Subpoena To Compel Production of Individually Indentifiable Health Information |
Oregon | October 1, 2014 |
| Subpoena To Compel Production |
Oregon | October 1, 2014 |
| Request For Board Review |
Oregon | October 1, 2014 |
| Cost Bill Form |
Oregon | October 1, 2014 |
