Authorized Forms

Note: All forms are in PDF format. Click the title to access form.

Title	Form Description
STD 27	File Injury Reporting Notification for Employers
STD 28	File Injury Reporting Notification for Injured Employees
STD 29	Authorization of Medical Treatment
WC 01	File an Injury or Disability Claim
WC 02	File Claim to Recover Damages from a Third-Party
DB 01	File a Death Benefit Claim
WC E1	Employer's Official Response to Filed Claim
DB E1	Employer's Official Response to Death Benefit Claim
PER 37	Dispute Claim & Controvert Right of Compensation
RH 01	File a Hearing Order
NO 01	Notice to Dismiss or Withdrawal a Filed Claim
NO 02	File an Official Complaint Against a Minor / Exempt Employer
NO 03	Notification of Remarriage
NO 04	Report Fraud
ME 01	First Medical Reporting on Treatments by Physician
ME 02	Request for a Permanent Impairment Disability Evaluation
ME 03	Request for Secondary Medical Opinion
ME 04	Determination of Employee's Ability to Return and Resume Work
ME 05	Certification as a Qualified Doctor
CS 01	Payment Claim for Legal Fees & Other Related Claim Services
LP 72	Required Notice of First, Suspended, & Final Payment
PY-01	Supplementary Order on Payment Default
PT 01	Petition for a Modification Order
PT 02	Petition for a Lump Sum Settlement
PT 03	Petition for Application of Penalty on Late Payment
RQ 01	Request for a Verification Letter on Award or Coverage
RQ 02	Request to Become a Party in Interest
INS 01	Authorization to Provide WC Insurance under the ASWCA
INS 02	Authorization for Self-Insurance
INS 03	Policy Cancellation Notification
EC-01	Clearance to File a Compliance Certificate