| First Report of Injury |
|
| Notice of First Payment |
|
| Notice of Denial of Claim for Compensation |
|
| Notice of Change or Termination of
Benefits |
|
| Notice of Controversy |
|
| Notice of Lawsuit |
|
| Final Report of Payment |
|
| Attending Physicians Report |
|
| Final Medical Report |
|
| Medical Waiver and Consent |
|
| Medical Report in Leiu of Deposition |
|
| Case Management Notification |
|
| Case Management Closure Form |
|
| Case Management Closure Form Instructions |
|
| Utilization Review Notification |
|
| Utilization Review Closure Form |
|
| Utilization Review Closure Form Instructions |
|
| Case Management Registration |
|
| Provider Registration for Utilization
Review |
|
| Request for Assistance |
|
| Request for Benefit Review Conference |
|
| Wage Statement |
|
| Agreement Between Employer/Employee
Choice of Physician |
|
| Governmental Entities Agreement Between
Employer/Employee Choice of Physician |
|
| CMUR Guidelines |
|
| Drug-Free Workplace Form |
|
| Proof of Coverage Memo |
|
| Reduction in Workforce |
|
| Sole Proprietor/Partner Selection |
|
| Sole Proprietor/Partner Withdrawal
of Election |
|
| Corporate Officer Election Not to Accept |
|
| Corporate Officer Withdrawal of Election |
|
| Exempt Employers Notice of Acceptance |
|
| Exempt Employers Withdrawal of Notice |
|
| Heart Waiver |
|
| Occupational Disease Waiver |
|
| Epilepsy Waiver |
|
| Waiver Withdrawal |
|
| Leased Operator/Common Carrier Election |
|
| Subcontractor/General Contractor Election |
|
| Leased Operator/Common Carrier Withdrawal |
|
| Subcontractor/General Contractor Withdrawal |
|
| Notice of Discontinuance |
|
| MIR Application for a Medical Impairment
Rating |
|
| MIR Application for Appointment to
the Medical Impairment Rating Registry |
|
| MIR Medical Waiver and Consent Form |
|
| MIR Report |
|
| Posting Notice |
|
| Posting Notice - Spanish |
|
| Request for Settlement Approval |
|
| Statistical Data Form |
|
| Statistical Data Form Instructions |
|
|
|
