| Title | State |
Last Updated |
| General Business Supplemental Questionnaire |
Utah | July 11, 2012 |
| Request Or Appeal For Additional Medical Information |
Utah | July 11, 2012 |
| Dependents Benefit Information |
Utah | July 11, 2012 |
| Employee Medical And Work Status Form |
Connecticut | July 11, 2012 |
| Employees Request To Change Treating Doctors (Non Network) |
Texas | July 11, 2012 |
| Statement Of Pharmacy Services |
Texas | July 11, 2012 |
| Tennessee Workers Compensation Insurance Notice To Be Posted At Employers Place Of Business (Spanish) |
Tennessee | June 25, 2012 |
| Tennessee Workers Compensation Insurance Notice To Be Posted At Employers Place Of Business |
Tennessee | June 25, 2012 |
| Request For Benefit Review Conference |
Tennessee | June 25, 2012 |
| Request For Assistance |
Tennessee | June 25, 2012 |
| Notice Of Corporate Officer Not To Accept Workers Compensation Act |
Tennessee | June 25, 2012 |
| Medical Impairment Rating (MIR) Impairment Rating Report 6th Edition |
Tennessee | June 25, 2012 |
| Certificate Of Readiness |
Tennessee | June 25, 2012 |
| Case Manager Registration |
Tennessee | June 25, 2012 |
| Application For A Medical Impairment Rating (MIR) |
Tennessee | June 25, 2012 |
| Request To Schedule, Reschedule, Or Cancel A Benefit Review Conference (BRC) |
Texas | December 1, 2011 |
| Insurance Carrier Or Trading Partner Medical Electronic Data Interchange (EDI) Profile |
Texas | August 12, 2011 |
| Petition For Lump Sum Payment Return To Work |
New Mexico | July 29, 2011 |
| Petition For Partial Lump Sum Payment For Debts |
New Mexico | July 29, 2011 |
| Employers First Report Of Injury Or Illness |
New Mexico | July 27, 2011 |
| Response (Of Employer To Workers Complaint) |
New Mexico | July 27, 2011 |
| Election To Accept (Employers Election To Accept WC Coverage) |
New Mexico | July 27, 2011 |
| Workers Response To Complaint |
New Mexico | July 27, 2011 |
| Revocation (Of Election To Accept WC Coverage Or Affirmative Election Of Exemption From WC Coverage) |
New Mexico | July 27, 2011 |
| Subpoena Or Subpoena Duces Tecum |
New Mexico | July 27, 2011 |
| Limited Liability Company Member Affirmative Election |
New Mexico | July 27, 2011 |
| Joint Petition For Lump Sum Settlement |
New Mexico | July 27, 2011 |
| Health Care Provider Disagreement Form - Request For Change Of Health Care Provider |
New Mexico | July 27, 2011 |
| Executive Employee Affirmative Election |
New Mexico | July 27, 2011 |
| Election To Refuse |
New Mexico | July 27, 2011 |
| Assessment Report 2010 |
Alabama | June 20, 2011 |
| Exclusion Form |
Maryland | April 5, 2011 |
| Notice To Health Care Provider And Injured Worker Of Carriers Refusal To Pay All (Or Portion Of) Medical Bill |
New York | February 14, 2011 |
| Discharge Or Discrimination Complaint |
New York | February 14, 2011 |
| Notice Of Right To Reimbursement Of Compensation Payments |
New York | February 14, 2011 |
| Reclamacion Del Empleado |
New York | February 1, 2011 |
| Practitioners Report Of Request For Information Or Response To Request Regarding Independent Medical Examination |
New York | February 1, 2011 |
| Agreed Upon Findings And Awards For Proposed Conciliation Decision (Represented Claimants Only) |
New York | January 14, 2011 |
| Locations Of Employers Business(es) |
Texas | January 6, 2011 |
| Workers Compensation Statistical Data Form |
Tennessee | December 4, 2010 |
| Notice Of Controversy |
Tennessee | December 4, 2010 |
| Case Management Notification |
Tennessee | December 4, 2010 |
| Weekly Net Income Worksheet |
Vermont | December 4, 2010 |
| Report Of Benefits And Related Expenses Paid |
Vermont | December 4, 2010 |
| Agreement For Permanent Partial Or Permanent Total Disability Compensation |
Vermont | December 4, 2010 |
| Agreement For Compensation In Fatal Cases |
Vermont | December 4, 2010 |
| Authorization To Release Claims History |
Idaho | December 3, 2010 |
| Request For Assistance (Or Mediation) |
Tennessee | December 3, 2010 |
| Provider Registration For Utilization Review |
Tennessee | December 3, 2010 |
| Medical Waiver And Consent |
Tennessee | December 3, 2010 |
