Request to Leave State Form


An injured worker may not leave the state for a period exceeding two weeks, (15 days or more), while the need for active medical treatment continues, without the written approval of the Commission.  This form may be used to request approval to leave the state. It must be completed in its entirety including the reason for the request. Failure to state the reason for the request may cause a delay in processing.

The Commission will issue an award either approving or disapproving the request to leave the state.   If approved, the effective date which grants permission for the injured worker to leave the state is the date on which the injured worker filed this request.

Adobe ESign Form