Special Funds Workers Supplemental Claim For Compensation

The injured worker and treating physician will be instructed to complete this form while the injured worker is on a no work status. It must be completed in its entirety. 

IMPORTANT:  Any person who knowingly makes a false statement or representation to obtain any compensation, benefit or payment is guilty of a class 6 felony and is subject to up to one and one-half years in prison, a fifty thousand dollar fine and forfeiture of benefits.