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Form

Description

IC-IA-1.pdf First Report of Injury or Illness
eng-sp.pdf First Report of Injury Instructions
ic14.pdf Employer's Supplemental Report
ic432.pdf Reimbursement for Health Care Travel Expenses
ic6.pdf Summary of Payments in Non-Fatal Cases
ic6f.pdf Summary of Payments in Fatal Cases
ic8.pdf Notice of Claim Status
ic52.pdf Election of Coverage
ic53.pdf Declaration of Exemption
ic53inst.pdf Instructions for form IC-53
cv.pdf Certificate of Verification of Workers' Compensation Insurance
cv-inst.pdf Instructions for Certificate of Verification Form
medreq.pdf Mediation Request Form
ic1001.pdf Workers' Compensation Complaint
isifintent.pdf Notice of Intent to File Complaint Against Industrial Special Indemnity Fund
ic1002.pdf Complaint Against the Industrial Special Indemnity Fund
ic1003.pdf Answer to Workers' Compensation Complaint
ic1007.pdf Subpoena
copwork.pdf Petition for Change of Physician
copemp.pdf Response to Petition for Change of Physician
disclosure.pdf Attorney Disclosure Statement
ic1022.pdf Report of Litigation Expenses (Claimant's Attorney)
ic1023.pdf Report of Litigation Expenses (Employer/Insurer Attorney)
motion-dispute.pdf Motion for Approval of Disputed Charge
resp-motion-dispute.pdf Reponse to Motion for Approval of Disputed Charge
additl-evid.pdf Motion to Present Additional Evidence
reconsideration.pdf Motion for Reconsideration
ic36.pdf Report of Outstanding Awards for Fatal, Permanent Partial Impairment, and Permanent Total Disability Claims
ic36inst.pdf Instructions for form IC-36 Report of Outstanding Awards for Fatal, Permanent Partial Impairment, and Permanent Total Disability Claims
ic327.pdf Workers' Compensation Claims Involving Medical Payments Only and Claims Involving Indemnity Payments Report
ic327inst.pdf Instructions for IC-327 Workers' Compensation Claims Involving Medical Payments Only and Claims Involving Indemnity Payments Report
ic4006.pdf Self-Insurance Application
self_insd_ind_guar_agree.pdf Self-Insured Indemnity and Guaranty Agreement
self_insd_consent_brd_dir.pdf Self-Insured Consent of the Board of Directors
ic4006sup.pdf Supplemental to Self-Insurance Application
self_insured_bond.pdf Self-Insurer's Compensation Bond
ic211.pdf Self-Insured Employer Report of Total Unpaid Liability
ic4008.pdf Semi-Annual Report Workers' Compensation Premium Tax
ic4008ld_inst.pdf Instructions for IC-4008LD
ic4008ld.pdf Workers' Compensation Policy Deductible Report
ic4010.pdf Semi-Annual Report Workers' Compensation Tax Report for Self-Insured Employers
ic4010a.pdf Self-Insured Employer Semi-Annual Premium Tax Computation
contact-form.pdf Contact Form
ic9030.pdf Rehabilitation Division Referral Form
rmr_1.pdf Request for Workers' Compensation Records by Parties
rmr_2.pdf Employer Certificate and Request for Work History - For Employers Subject to the ADA
rmr_3.pdf Employer Certificate and Claims History Release - For Employers NOT Subject to the ADA
rmr_4.pdf Claimant's Request for Personal Workers' Compensation Records
rmr_5.pdf Request for Records Other than Workers' Compensation Records
rmr_6.pdf Request for Microfilmed Workers' Compensation Records by Parties
facts_for_iw.pdf BROCHURE - Facts for Injured Workers
facts_for_ers.pdf BROCHURE - Facts for Employers
rehab_svcs.pdf BROCHURE - Rehabilitation Services for Injured Workers
guide_for_employers.pdf BROCHURE - A Guide for Employers of Injured Workers
poster.pdf POSTER - Notice Regarding Workers' Compensation - There are no firm rules on exactly what this notice must look like. It is normally printed on an orange or salmon card stock so that it will be noticed.
poster_sp.pdf POSTER - Notice Regarding Workers' Compensation (Spanish)- There are no firm rules on exactly what this notice must look like. It is normally printed on an orange or salmon card stock so that it will be noticed.
app-for-waiver.pdf Application for Waiver