Form Number | Form Name | Last Updated |
---|---|---|
ALJ_8801 | Interested Party Workers’ Compensation Document Submission | 03/07/18 |
Form Number | Form Name | Last Updated |
---|---|---|
ADOSH_2212 | Report a Fatality or Severe Injury Form | 08/12/16 |
ADOSH_2213 | Notice of Alleged Safety or Health Hazards Form | 09/16/16 |
ADOSH_2215 | Discrimination Complaint Form | 09/16/16 |
ADOSH_2217 | Consultation Request Form | 08/12/16 |
ADOSH_2218 | ADOSH Training Request Form | 08/12/16 |
ADOSH_2219 | ADOSH Standards Book Order Form | 08/12/16 |
ADOSH_2221 | Application for Permit to Install or Alter Elevator Form | 08/12/16 |
ADOSH_2222 | Request for Boiler Repair Form | 08/12/16 |
ADOSH_2223 | Request for Boiler Certificate Form | 08/12/16 |
Form Number | Form Name | Last Updated |
---|---|---|
Claims_0446 | Request for Hearing Form | 07/12/17 |
Claims_0101 | Employer Report of Injury Form | 09/16/16 |
Claims_0102 | Worker’s and Physician’s Report of Injury Form | 05/19/17 |
Claims_0407 | Worker’s Report of Injury Form | 07/12/17 |
Claims_0121 | Request to Change Doctors Form | 09/16/16 |
Claims_0122 | Request to Leave State Form | 09/16/16 |
Claims_110A | Annual Report of Income Form | 08/12/16 |
Claims_110B | Notice of Intent to Suspend Form | 08/12/16 |
Claims_0528 | Petition to Reopen Form | 07/12/17 |
Claims_0529 | Petition for Rearrangement Form | 09/16/16 |
Claims_0120 | Dependent Benefits Claim Form | 07/12/17 |
Claims_0123 | Professional Employer Agreement Form | 09/16/16 |
Claims_0124 | Bodily Fluids Work Exposure Form | 09/16/16 |
Claims_0113 | Employee Rejection of Terms Form | 08/12/16 |
Claims_0114 | Employee Revocation of Rejection of Terms Form | 08/23/16 |
Form Number | Form Name | Last Updated |
---|---|---|
Labor_3303 | Claims for Unpaid Wages | 12/28/17 |
Labor_3304 | Public Complaint form Youth Employment and Labor Law Violations | 12/28/17 |
Labor_3305 | Earned Paid Sick Time Complaint Form | 12/28/17 |
Labor_3325 | Minimum Wage Complaint Form | 12/28/17 |
Form Number | Form Name | Last Updated |
---|---|---|
Legal_4401 | Public Records Request Form | 09/26/17 |
Legal_4402 | Uninsured Employer Complaint Form | 07/12/17 |
Legal_4403 | Employers Workers Compensation Insurance Inquiry Response Form | 07/12/17 |
Legal_4404 | Petition for Attorney’s Fees | 03/08/18 |
Form Number | Form Name | Last Updated |
---|---|---|
MRO_7701 | Preauthorization Request and Payer Decision Form | 08/12/16 |
MRO_7702 | Request for Administrative Peer Review Form | 08/12/16 |
Form Number | Form Name | Last Updated |
---|---|---|
SpecFund_5413 | Workers Supplemental Claim Form 413 | 08/12/16 |
SpecFund_5525 | Carrier's Notification of Scheduled Injury Time Loss | 08/12/16 |
SpecFund_5526 | Workers Supplemental Claim For Compensation | 01/18/17 |
SpecFund_5527 | Apportionment Settlement Letter | 01/05/18 |
SpecFund_5528 | Vocational Rehabilitation Referral | 01/05/18 |