Workers' Compensation
- WC-1 Employer's Report of Industrial Injury
- Instruction Sheet
- WC-2 Physician's Report
- WC-5 Employee's Claim for Workers' Compensation Benefits
- WC-5A Dependents' Claim for Compensation
- WC-14 Employee's Wage Report
- WC-21 Application for Self-Insurance
- WC-42 Request for Information or Photo Copies
- WC-77 Application for Hearing
- WC-77A Response to Application for Hearing
- Request for Approval of Attorney's Fee
Temporary Disability Insurance (TDI)
For employees:
Claim forms are not available online. Ask your employer for a claim form or contact us if your employer does not have the claim form.
FOR EMPLOYERS:
Prepaid Healthcare (PHC)
- HC-5 Employee Notification to Employer: 2021
For employers:
- HC-4 Health Care Coverage Questionnaire
- HC-6 Small Employers Subject To PHC / Employer's Request for Premium Supplementation
- HC-61 Application For Self-Insurance Auth
For Health care Contractors:
- HC-7 Application for Plan Review
- HC-7(a-1) “Reimbursement” type plans (A summary of benefits of the prevalent PPO plan.)
- HC-7(a-2) “Service” type plans (A summary of benefits of the prevalent HMO plan.)
General Forms
