| Title |
Last Updated |
| Application For Death Benefits And Or Funeral Expenses |
June 25, 2019 |
| Request For Temporary Total Compensation |
May 8, 2019 |
| Injured Worker Earnings Statement |
May 3, 2019 |
| Request For Injured Worker Outpatient Medication Reimbursement |
April 1, 2019 |
| First Report Of An Injury Occupational Disease Or Death |
October 4, 2018 |
| Application For Payment Of Lump Sum Advancement |
October 4, 2018 |
| Application For Determination Of Percentage Of Permanent Partial Disability |
September 11, 2018 |
| Application For Accrued Compensation |
March 6, 2018 |
| Rehabilitation Agreement |
March 7, 2017 |
| Request For Prior Authorization Of Medication |
November 30, 2016 |
| Authorization For Living Maintenance Wage Loss (LMWL) |
June 22, 2016 |
| Affidavit For Attorney Fees |
November 12, 2015 |
| Authorization To Receive Workers Compensation Payment |
April 13, 2015 |
| Motion |
April 13, 2015 |
| Injured Worker Statement Reimbursement Of Travel Expense |
April 13, 2015 |
| Authorization To Release Medical Information |
April 13, 2015 |
| Notice To Change Physician Of Record |
April 13, 2015 |
| Direct Deposit ACT Bank Change |
April 13, 2015 |
| Injured Worker Reimbursement Rates For Travel Expense |
February 25, 2015 |
| Injured Worker Authorized Representative |
February 25, 2015 |
| Request For Prior Authorization Of Medication Form |
July 15, 2013 |
| Consent To Release Information |
January 10, 2013 |
| Waiver Of Appeal Period |
July 11, 2012 |
| Request For Medical Information |
March 29, 2011 |
| ACT Enrollment And Direct Deposit Authorization |
March 28, 2011 |
| Additional Information For Death Benefits |
March 28, 2011 |
| Annual Death Benefits Questionnaire |
January 14, 2011 |
| Wage Agreement |
February 10, 2010 |
| Wage Loss Statement For Job Search |
June 2, 2009 |
| Gradual return To Work Agreement |
June 1, 2009 |
| Injured Workers Record Of Job Search Contacts |
February 5, 2009 |
| On The Job Training Agreement |
November 6, 2008 |
| Request For Prior Authorization of Non-Preferred Medication Form |
June 3, 2008 |
| Self Insured Joint Settlement Agreement And Release |
September 14, 2005 |
| Authorization To Receive Workers Compensation Check |
September 14, 2005 |
| Application For Determination Of Percentage Of Permanent Partial Disability Or Increase Of Permanenet Partial Disability |
September 21, 2004 |
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