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Workers’ Compensation Documents

Title Link to File
Form 14-0159 — Combination Settlement Combination Settlement -- Form 14-0159.pdf
Form 14-0083 — Information Request Information Request -- Form 14-0083.pdf
Form 14-0075 — Application to Defer Payment of Filing Fees & Financial Affidavit Application to Defer Payment of Filing Fees & Financial Affidavit -- Form 14-0075.pdf
Form 14-0043 — Authorization to Release Information Regarding Claimant Seeking Workers' Compensation Benefits Form 14-0043 -- Authorization to Release Claimant Information.pdf
Form 14-0037 — Application for Payment of Benefits Application for Payment of Benefits -- Form 14-0037.pdf
Form 14-0025 — Compromise Settlement Compromise Settlement -- Form 14-0025.pdf
Form 14-0021 — Full Commutation of Benefits Full Commutation of Benefits -- Form 14-0013.pdf
Form 14-0021 — Agreement for Settlement Agreement for Settlement -- Form 14-0021.pdf
Form 100D (14-0012A) — Answer Concerning Vocational Training & Education Answer Concerning Vocational Education & Training -- Form 100D (14-0012A).pdf
Form 100D (14-0012) — Original Notice & Petition Concerning Vocational Training & Education Original Notice & Petition Concerning Vocational Training & Education -- Form 100D (14-0012).pdf
Form 100C (14-0011A) — Answer Concerning Application for Alternate Care Answer Concerning Application for Alternate Care -- Form 100C (14-0011A).pdf
Form 100C (14-0011) — Original Notice & Petition Concerning Application for Alternate Care Original Notice & Petition Concerning Application for Alternate Care -- Form 100C (14-0011).pdf
Form 100B (14-0009A) — Answer Concerning Vocational Rehabilitation Program Benefit Answer Concerning Vocational Rehabilitation Program Benefit -- Form 100B (14-0009A).pdf
Form 100B (14-0009) — Original Notice & Petition Concerning Vocational Rehabilitation Program Benefit Original Notice & Petition Concerning Vocational Rehabilitation Benefit -- Form 100B (14-0009).pdf
Form 100A (14-0007A) — Answer Concerning Independent Medical Examination (IME) Answer Concerning Independent Medical Examination -- Form 100A (14-0007A).pdf
Form 100A (14-0007) — Original Notice & Petition Concerning Independent Medical Examination (IME) Original Notice & Petition Concerning Independent Medical Examination -- Form 100A (14-0007).pdf
Form 100 (14-0005) — Original Notice & Petition Original Notice & Petition -- Form 100 (14-0005).pdf
Fee Schedule for Information Requests Fee Schedule for Information Requests.pdf
Corporate Officer Exclusion Form 14-0061corpofficerex.pdf
Brochure: Questions & Answers for Injured Workers (July 1, 2023–June 30, 2024) Workers' Compensation Questions and Answers Brochure -- 2023-24.pdf
10% Interest Table 05tenpercenttable.pdf