Workers' Compensation-Related Forms
The forms listed below are those commonly used in the Employment Relations functions of the workers' compensation system. You can use the following form to order these in quantity. Order Form
FIRST REPORT OF INJURY (Revised 01/05/06)
Legal size form recommended
for those who wish to complete on a typewriter or long hand.
Letter size form
this form is in WORD form format for those who wish to complete it on
their computer.
FROI Instructions
· Simply tab through the fields to complete the form.
·Used by an injured worker to report an injury or occupational disease
to his/her employer.
·Used by an employer to report an injured worker's injury or occupational
disease to the employer's insurer/adjuster.
·Used by an insurer/adjuster to report claim data to the Department.
SUBSEQUENT REPORT
OF INJURY
Used by insurer/adjuster to report on-going claim data to the Department.
THIRD PARTY AGENT/ADJUSTER CHANGE
FORM
Used to report changes in adjuster, claim administrators,
or third party administrators.
THIRD PARTY ADMINISTRATOR PROFILE
Used for adding new Third Party Administrators (TPA) and for changes to contact information for existing TPAs .
ELECTRONIC DATA INTERCHANGE
(EDI) FORMS
Used by insurers and adjusters as a quick, efficient method of communicating
data to the Department.
· Trading Partner Agreement
· Third Party Administrator Attachment
· Trading Partner Profile
· ERD/TP Profile
PETITION
FOR WORKERS' COMPENSATION MEDIATION CONFERENCE
Used by and injured worker or and adjuster or insurer to request a mediation
conference in order to resolve a dispute over workers' compensation
benefits.
MEDICAL
PROVIDER BILLING REQUEST FORM
Used by a medical provider to obtain from the Department sufficient
information to send an injured worker's medical bill to the proper insurer
or adjuster.
ELECTRONIC
PRIOR CLAIMS (EPC) HISTORY ACCESS AGREEMENT
Used by an insurer to obtain access to the EPC system in order to obtain
prior claim history on their claimants.
ATTORNEY
RETAINER DOCUMENT
Used by an attorney to formalize fee contract with an injured worker.
PETITION
FOR SETTLEMENT - DISPUTED INITIAL COMP
Used by insurer/adjuster when parties have agreed to compromise
and settle disputes on a claim. Used when initial compensability of
a claim is disputed.
PETITION
FOR SETTLEMENT - INJURY/OD
Used by an insurer/adjuster when parties have agreed to a compromise
and release settlement of the claim.
SETTLEMENT/ADVANCE
RECAP SHEET
Used by insurer/adjuster, in conjunction with a petition for Settlement
or request for lump sum payment.
OTHER FORMS
Beneficiaries' Claim for Compensation
Physician's Referral to Domiciliary Care
