Forms
Forms
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Static forms need to be printed and completed manually.
Interactive forms may be opened online or downloaded to your PC and completed at a later time when offline. Interactive forms enable the user to enter information directly into the forms. Forms which require a signature or other type of manual authentication need to be printed, signed or authenticated, then transmitted to this office.
| Form Number | Form Name | Last Updated |
|---|---|---|
| Claims_0113 | Employee Rejection of Terms Form | 08/12/16 |
| Claims_110A | Annual Report of Income Form | 08/12/16 |
| Claims_110B | Notice of Intent to Suspend Form | 08/12/16 |
| Claims_0114 | Employee Revocation of Rejection of Terms Form | 08/23/16 |
| Claims_0124 | Bodily Fluids Work Exposure Form | 09/16/16 |
| Claims_0123 | Professional Employer Agreement Form | 09/16/16 |
| Claims_0446 | Request for Hearing Form | 06/07/19 |
| Claims_0101 | Employer Report of Injury Form | 06/07/19 |
| Claims_0121 | Request to Change Doctors Form | 06/07/19 |
| Claims_0122 | Request to Leave State Form | 06/07/19 |
| Claims_0528 | Petition to Reopen Form | 06/07/19 |
| Claims_0529 | Petition for Rearrangement Form | 06/07/19 |
| Claims_0120 | Dependent Benefits Claim Form | 06/07/19 |
| Claims_0102 | Worker’s and Physician’s Report of Injury Form | 12/06/19 |
| Claims_0407 | Worker’s Report of Injury Form | 03/23/22 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| SpecFund_5525 | Carrier's Notification of Scheduled Injury Time Loss | 08/12/16 |
| SpecFund_5413 | Workers Supplemental Claim Form 413 | 08/12/16 |
| SpecFund_5526 | Workers Supplemental Claim For Compensation | 01/18/17 |
| SpecFund_5528 | Vocational Rehabilitation Referral | 06/07/19 |
| SpecFund_5527 | Apportionment Settlement Letter | 02/01/21 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| Legal_4403 | Employers Workers Compensation Insurance Inquiry Response Form | 07/12/17 |
| Legal_4404 | Petition for Attorney’s Fees | 03/08/18 |
| Legal_4401 | Public Records Request Form | 04/01/20 |
| Legal_4402 | Uninsured Employer Complaint Form | 09/03/20 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| ALJ_8801 | Interested Party Workers’ Compensation Document Submission | 03/07/18 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| MRO_7711 | Medical Treatment Preauthorization Form | 09/27/18 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| ADOSH_2225 | VPP Pre-Screening Form | 06/25/21 |
| ADOSH_2224 | Compliance Assistance Request Form | 06/30/21 |
| ADOSH_2226 | SHARP Application Form | 06/13/22 |
| ADOSH_2227 | Elevator Inspection (PEI) New Application | 03/20/23 |
| ADOSH_2212 | Report a Fatality or Severe Injury Form | 03/20/23 |
| ADOSH_2213 | Notice of Alleged Safety or Health Hazards Form | 03/20/23 |
| ADOSH_2215 | Discrimination / Whistleblower Complaint Form | 03/20/23 |
| ADOSH_2217 | Consultation Request Form | 03/20/23 |
| ADOSH_2218 | ADOSH Training Request Form | 03/20/23 |
| ADOSH_2221 | Application for Permit to Install or Alter Elevator Form | 03/20/23 |
| ADOSH_2222 | Request for Boiler Repair Form | 03/20/23 |
| ADOSH_2223 | Request for Boiler Certificate Form | 03/20/23 |
| ADOSH_2232 | Boiler Inspector (PBI) Renewal Application | 03/20/23 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| Labor_3303 | Unpaid Wage Claim Form | 02/25/22 |
| Labor_3325 | Minimum Wage Claim Form | 02/25/22 |
| Labor_3305 | Earned Paid Sick Time Claim Form | 02/25/22 |
| Labor_3307 | EPST/Minimum Wage Retaliation Claim Form | 02/25/22 |
| Labor_3306 | Youth Labor Complaint Form | 02/25/22 |
| Labor_3304 | Payment Compliance Complaint Form | 02/25/22 |
