Below is a list of all the State Forms for the Worker's Compensation Board listed in numerical order. You may click the form name or the form number to download a fillable PDF version. If you cannot locate a form or wish to search for one specifically, please use the search tool found here.
To find the Self-Insurance forms, please click here.
Information about the 2nd Injury Fund and it's associated forms, please click here.
| State Form Name | Form Number |
|---|---|
| Application for Review by Full Board | 1042 |
| Agreement to Compensation | 1043 |
| Physician's Report | 2118 |
| Provider Fee Application for Adjustment of Claim | 18487 |
| Agreement to Compensation Between the Dependents of Deceased Employee and Employer | 18875 |
| Application for Adjustment of Claim | 29109 |
| First Report of Injury** | 34401 |
| Agreement Between Parties for Lump Sum Payment | 34873 |
| Subpoena | 34877 |
| Notice for Worker's Compensation and Occupational Diseases Coverage** | 36097 |
| Report Of Temporary Total Disability (TTD)/Temporary Partial Disability (TPD) Termination** | 38911 |
| Request for Assistance | 45442 |
| Application for Worker's Compensation Clearance Certificate (English) | 45889 |
| Application for Worker's Compensation Clearance Certificate (Spanish) | 55718 |
| Notice of Inability to Determine Liability / Request for Additional Time** | 48557 |
| Application for Second Injury Fund Benefits | 51247 |
| Request for Prosthetic Repair or Replacement | TBD |
| Provider Fee Request for Assistance | 52875 |
| Request for Public Record | 53811 |
| Employee Waiver of Examination by Personal Physician | 53913 |
| Notice of Denial of Benefits** | 53914 |
| Notice of Suspension of Compensation and/or Benefits | 54217 |
| Certification of Insurance Carrier as to Number of Worker's Compensation Policies Written or Renewed | 55310 |
| Summary of Benefits Paid | TBD |
**Please note that all forms marked by an asterisk are required to be submitted electronically via an approved EDI 3.1 process. Forms submitted to the Board in hard copy prior to being submitted electronically will be rejected.