WC-36 This form can only be completed by Workers’ Compensation carriers. Contact your carrier for information.
Temporary Disability Insurance (TDI)
TDI-45 Claim for Disability Benefit forms are not available online. Ask your employer for a claim form or contact us if your employer does not have the claim form.
TDI-15 TDI Self-Insurer’s Plan Certification & Agreement – This link is being updated! Please come back later.
TDI-62 This form can only be completed by TDI carriers. Contact your TDI carrier for more information.
Prepaid Health Care (PHC)
HC-5 for 2015 HC-5 Employee Notification to Employer
HC-5 for 2014 HC-5 Employee Notification to Employer
HC-15 This form can only be completed by PHC plan contractors. Contact your PHC plan contractor for information.
For health care contractors:
HC-7(a-1) “Reimbursement” type plans (A summary of benefits of the prevalent PPO plan.)
HC-7(a-2) “Service” type plans (A summary of benefits of the prevalent HMO plan.)