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Indiana Form Center -

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Form

Description

34401.pdf First Report of Injury - *** Must Be Sent Electronically to The Workers Compensation Board of Indiana ***
POSTENGL.pdf POSTER - Worker's Compensation Notice
POSTSPAN.pdf POSTER - Worker's Compensation Notice (Spanish)
2118.pdf Report of Attending Physician
Form01042.pdf Application for Review by Full Board
18487.pdf Application for Adjustment of Claim for Provider Fee
52875.pdf Provider Fee Request for Assistance
29109.pdf Application for Adjustment of Claim
Form01043.pdf Agreement to Compensation
38911.pdf Report of Temporary Total Disability (TTD) / Temporary Partial Disability (TPD) Termination / Reduction
45442.pdf Request for Assistance
48557.pdf Notice of Inability to Determine Liability/Request for Additional Time
51247.pdf Application for Second Injury Fund
51702.pdf Request for Prosthetic Repair or Replacement
34873.pdf Agreement Between Parties for Lump Sum Payment
18875.pdf Agreement to Compensation Between the Dependents of Deceased Employee and Employer
53913.pdf Employee Waiver of Examination by Personal Physician
54217.pdf Notice of Suspension of Medical Benefits
53914.pdf Notice of Denial of Benefits
53811.pdf Request for Public Record
36097.pdf Notice for Workers' Compensation and Occupational Diseases Coverage
34877.pdf Subpoena
Guidelines.pdf Workers' Compensation Self Insurance Guidelines
si-1.pdf Employer's Application for Permission to Carry Risk Without Insurance
si-2.pdf Surety Bond
si-3.pdf Certificate of Excess Insurance
si-4.pdf Parental Indemnity Agreement
si-5.pdf Employer's Request to Include a Subsidiary within its Self-Insurance Program
si-7.pdf Trucker's Supplemental Application
12386-b.pdf Certification of Workers Compensation Carriers
55310.pdf Certification of Insurance Carrier as to Number of Workers' Compensation Policies Written or Renewed
45899.pdf Application for Workers' Compensation Clearance Certificate
55718.pdf Application for Workers' Compensation Clearance Certificate (Spanish)
TPAApplication.pdf Service Company Application for Permission to Serve Indiana Self-Insured Employers
12386.pdf Self-Insured Employer Certification