Petitions and forms available for downloading
are highlighted.
(Updated January 2009)
| M-1 |
Practitioner's Report Eff 6/99 (Word 97) |
| M-1 |
Practitioner's Report (PDF) |
| M-2 |
Request for Independent Medical Examination Eff 6/99 (Word 97 format) |
| M-2 |
Request for Independent Medical Examination (PDF) |
| M-3 |
Medical Utilization Review to Change Health Care Provider |
| M-4 |
Denial of Request to Change Health Care Provider |
| WCB-1 |
Employer's First Report of Injury Eff 1/02 (PDF) |
| WCB-1 |
Employer's First Report of Injury (Word 97) |
| WCB-1B |
Employee Information Letter |
| WCB-2 |
Wage Statement Eff 8/94 (Word 97) |
| WCB-2 |
Wage Statement (PDF) |
| WCB-2A |
Schedule of Dependent(s) and Filing Status Statement Eff 8/94 (Word
97) |
| WCB-2A |
Schedule of Dependent(s) and Filing Status Statement (PDF) |
| WCB-2C |
Application for Waiver Eff 4/08 (Word 97) |
| WCB-2C |
Application for Waiver Eff 4/08 (RTF) |
| |
Application for
Waiver Instructions (Word
97) |
| WCB-3 |
Memorandum of Payment Eff 10/98 (Word Perfect 6.1) |
| WCB-3 |
Memorandum of Payment (Word 97) |
| WCB-3 |
Memorandum of Payment (PDF) |
| WCB-4 |
Discontinuance or Modification of Compensation Eff 8/94 (Word 97) |
| WCB-4 |
Discontinuance or Modification of Compensation (PDF) |
| WCB-4A |
Consent Between Employer and Employee Eff 3/97 (Word 97) |
| WCB-4A |
Consent Between Employer and Employee (PDF) |
| WCB-6 |
Certificate Authorizing Release of Benefit Information Eff 3/97
(Word 97) |
| WCB-6 |
Certificate Authorizing Release of Benefit Information (PDF) |
| WCB-7 |
Notice of Possible Unemployment Compensation Offset |
| WCB-8 |
Certificate of Discontinuance or Reduction of Compensation Eff
8/94 (Word 97) |
| WCB-8 |
Certificate of Discontinuance or Reduction of Compensation (PDF) |
WCB-9 |
Notice of Controversy Eff 1/06 (Word 97) |
| WCB-9 |
Notice of Controversy Eff 1/06 (PDF) |
| WCB-9 |
Notice of Controversy Eff 10/98 (PDF) |
| WCB-9 |
Notice of Controversy EDI Instructions Eff 4/22/08 (RTF) |
| WCB-10 |
Lump Sum Settlement Eff 3/98 (Word 97) |
| WCB-10 |
Lump Sum Settlement (PDF) |
| WCB-11 |
Statement of Compensation Paid Eff 3/98 (Word 97) |
| WCB-12 |
Employer's Supplemental Report Eff 8/94 (Word 97) |
| WCB-25 |
Motion for Award of Fees and DisbursementsEff 5/93 (Word 97) |
| WCB-80 |
Agreement Between Employer and Employee as to Permanent Impairment
(Word 97) |
| WCB-90 |
Notice to Workers (poster - last update 1/06) (PDF) |
| WCB-120 |
Petition for Review of Incapacity Eff 6/98 (Word 97) |
| WCB-121 |
Employee Petition for Review of Incapacity/Request for Provisional
Order Eff 6/98 (Word 97) |
| WCB-122 |
Petition to Determine Average Weekly Wage Eff 6/98 (Word 97) |
| WCB-140 |
Petition for Award of Compensation Eff 6/98 (Word 97) |
| WCB-150 |
Petition for Award of Compensation - Fatal Eff 6/98 (Word 97) |
| WCB-160 |
Petition for Award of Compensation - Occupational Disease Law
Eff 6/98(Word 97) |
| WCB-170 |
Petition for Restoration Eff 6/98 (Word 97) |
| WCB-171 |
Petition for Reinstatement Eff 6/98 (Word 97) |
| WCB-180 |
Petition to Determine Extent of Permanent Impairment Eff 6/98
(Word 97) |
| WCB-190 |
Petition for Payment of Medical and Related Services Eff 6/98
(Word) |
| WCB-190A |
Provider's Petition for Payment of Medical and Related Services
Eff 6/98 (Word 97) |
| WCB-195 |
Petition to Remedy Discrimination Eff 6/98 (Word 97) |
| WCB-220 |
Limited Certificate Authorizing Written Release of Medical/Health
Care Information Eff 4/96 (Word 97) |
| WCB-221 |
Certificate Authorizing Release of Information Eff 4/96 (Word 97) |
| WCB-230 |
Employment Status Report Eff 5/95 (Word 97) |
| WCB-231 |
Employee's Return to Work Report Eff 8/94 (Word 97) |
| WCB-250 |
Request for Expedited Proceeding Eff 8/94 (Word 97) |
| WCB-260 |
Application for Predetermination of Independent Contractor Status
to Establish Conclusive Presumption - Landowner/Woodharvester (Word
97) |
| WCB-260 |
Application for Predetermination of Independent Contractor Status
to Establish Conclusive Presumption - Landowner/Woodharvester (PDF) |
| WCB-261 |
Application for Predetermination of Independent Contractor Status
to Establish Rebuttable Presumption (Word 97) |
| WCB-261 |
Application for Predetermination of Independent Contractor Status
to Establish Rebuttable Presumption (PDF) |
| WCB-262 |
Application for a Certificate of Independent Status (Word 97) |
| WCB-262 |
Application for a Certificate of Independent Status (PDF)
|
| WCB-263 |
Application for Predetermination of Construction Subcontractor to Establish a Rebuttable Presumption (Word 03) |
| WCB-263 |
Application for Predetermination of Construction Subcontractor to Establish a Rebuttable Presumption (PDF) |
| WCB-310 |
Witness Subpoena for Hearing/Deposition - 2 pages (Word)
Available at any Regional Office |
|
Petition for Forfeiture (Word
97)
|
|
Application
for Voc Rehab (Word 97) |
| |
Complaint
for Audit (Word 97) |
|
Waiver to request for
Unemployment Information (Word 97) Available at any Regional Office
|
|
2009 Forms Manual |
** Quantities may
be reproduced locally or are available through Gossamer Press, Tel (207) 827-9881, Fax: (207)
827-9861
