Forms

Forms  |  Guidelines  |  Publications

Workers’ Compensation

WC-1 Employer’s Report of Industrial Injury

WC-2 Physician’s Report

WC-5 Employee’s Claim for Workers’ Compensation Benefits

WC-5A Dependents’ Claim for Compensation

WC-14 Employee’s Wage Report

WC-21 Application for Self-Insurance

WC-36 This form can only be completed by Workers’ Compensation carriers. Contact your carrier for information.

WC-42 Request for Information or Photo Copies

WC-77 Application for Hearing

WC-77A Response to Application for Hearing

Attorney Fee Request

Attorney Hourly Rate Increase Request

Temporary Disability Insurance (TDI)

For employees:

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.

For employers:

TDI-14 Equivalency Tables

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

For employers:

HC-4 Health Care Coverage Questionnaire

HC-6 Small Employers Subject to PHC/Employer’s Request for Premium Supplementation

HC-15 This form can only be completed by PHC plan contractors.  Contact your PHC plan contractor for information.

HC-61 Application for Self-Insurance Authorization

For health care contractors:

HC-7 Application for Plan Review

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.)

General Forms

DC-54 Complaint Form

LIR#27 Application for Certificate of Compliance with Section 3-122-112, HAR

Professional Employer Organization (PEO) Application