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Below is a list of all the State Forms for the Worker's Compensation Board listed in numerical order. You may click the form name or the form number to download a fillable PDF version. If you cannot locate a form or wish to search for one specifically, please use the search tool found here

To find the Self-Insurance forms, please click here.

Information about the 2nd Injury Fund and it's associated forms, please click here

State Form Name Form Number
Application for Review by Full Board 1042
Agreement to Compensation 1043
Physician's Report 2118
Provider Fee Application for Adjustment of Claim 18487
Agreement to Compensation Between the Dependents of Deceased Employee and Employer 18875
Application for Adjustment of Claim 29109
First Report of Injury** 34401
Agreement Between Parties for Lump Sum Payment 34873
Subpoena 34877
Notice for Worker's Compensation and Occupational Diseases Coverage 36097
Report Of Temporary Total Disability (TTD)/Temporary Partial Disability (TPD) Termination** 38911
Request for Assistance 45442
Application for Worker's Compensation Clearance Certificate (English) 45889
Application for Worker's Compensation Clearance Certificate (Spanish) 55718
Notice of Inability to Determine Liability / Request for Additional Time** 48557
Application for Second Injury Fund Benefits 51247
Request for Prosthetic Repair or Replacement 51702
Provider Fee Request for Assistance 52875
Request for Public Record 53811
Employee Waiver of Examination by Personal Physician 53913
Notice of Denial of Benefits** 53914
Notice of Suspension of Compensation and/or Benefits 54217
Certification of Insurance Carrier as to Number of Worker's Compensation Policies Written or Renewed 55310

**Please note that all forms marked by an asterisk are required to be submitted electronically via an approved EDI 3.1 process. Forms submitted to the Board in hard copy prior to being submitted electronically will be rejected.