| Title | State |
Last Updated |
| Workers Compensation Order Form |
Alabama | August 22, 2019 |
| Workers Compensation Information Poster |
Alabama | August 22, 2019 |
| Request For Further Action By Carrier-Employer |
New York | August 22, 2019 |
| Request For Assistance By Injured Worker |
New York | August 22, 2019 |
| WAMO Settlement Agreement Indemnity Section 32 WCL |
New York | August 15, 2019 |
| Order Form For Publications |
Kansas | August 6, 2019 |
| Notice And Proof Of Claim For Disability Benefits |
New York | July 29, 2019 |
| Claimants Record Of Job Search Efforts Contacts |
New York | July 22, 2019 |
| Notice Of Claim For Compensation (Employee To Commissioner And To Employer) |
Connecticut | July 19, 2019 |
| Vocational Rehabilitation Vendor Application |
Kansas | July 19, 2019 |
| Attending Physicians Report |
Virginia | July 18, 2019 |
| Coverage Election By Employee Who Is An Officer Or Member |
Connecticut | July 11, 2019 |
| Coverage Election By Sole Proprietor Or Single Member LLC |
Connecticut | July 9, 2019 |
| Authorization To Disclose Release And Use Protected Health Information (HIPAA Compliant) |
Utah | June 21, 2019 |
| Insurance Companys And Self Insurers Final Report Of Injury And Statement Of Total Losses |
Utah | June 20, 2019 |
| Insurance Carriers Self Insurers Notice Of Further Investigation Of A Workers Compensation Claim |
Utah | June 20, 2019 |
| Employee Notification Of Denial Or Partial Denial Of Claim |
Utah | June 20, 2019 |
| Employers First Report Of Injury Or Illness |
Utah | June 18, 2019 |
| Statement Of Insurance Carrier Or Self Insurer With Respect To Discontinuance Of Benefits |
Utah | June 14, 2019 |
| Initial Statement Of Insurance Carrier Self Insurer Payment Of Benefits |
Utah | June 14, 2019 |
| Medical Proof Of Change Re Application For Reopening Claim |
New York | June 10, 2019 |
| Employees Statement Of Exempt Status |
New York | June 10, 2019 |
| Disability Benefits Law Employer Identification Information |
New York | June 10, 2019 |
| Authorization For Disclosure Of Health Information |
Maryland | June 3, 2019 |
| Designated Doctor Examination Data Report |
Texas | May 30, 2019 |
| Standard Form Medical Report For Industrial Injuries |
Tennessee | May 24, 2019 |
| Notice Of Corporate Officers Revocation Of Exemption |
Tennessee | May 24, 2019 |
| Notice Of Change Or Termination Of Compensation Benefits |
Tennessee | May 24, 2019 |
| Complaint For Audit |
Maine | May 22, 2019 |
| Dispute Resolution Form (CorVel Corporation) |
South Dakota | May 22, 2019 |
| Amputation Chart |
Virginia | May 10, 2019 |
| Claim For Benefits |
Virginia | May 10, 2019 |
| Monthly Payment Report |
South Dakota | May 7, 2019 |
| Assumption Of Self Insurance Obligations |
South Dakota | May 7, 2019 |
| Employee Claim |
New York | April 26, 2019 |
| Medical Provider Billing Request |
Montana | April 18, 2019 |
| Statement Of Compensation Paid |
Maine | April 18, 2019 |
| Request For Expedited Proceeding |
Maine | April 18, 2019 |
| Notice Of Controversy |
Maine | April 18, 2019 |
| Memorandum Of Payment |
Maine | April 18, 2019 |
| Employee Expense Form |
Maine | April 18, 2019 |
| Discontinuance Or Modification Of Compensation |
Maine | April 18, 2019 |
| Consent Between Employer And Employee |
Maine | April 18, 2019 |
| Certificate Of Discontinuance Or Reduction Of Compensation |
Maine | April 18, 2019 |
| Workers Compensation Complaint |
New Mexico | April 9, 2019 |
| Summons For Application To Workers Compensation Judge |
New Mexico | April 9, 2019 |
| Notice Of Change Of Health Care Provider |
New Mexico | April 9, 2019 |
| Notice Of Disqualification |
New Mexico | April 9, 2019 |
| Notice Of Acceptance Or Rejection Of Recommended Resolution |
New Mexico | April 9, 2019 |
| Joint Waiver Of Disqualification |
New Mexico | April 9, 2019 |
