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New Hampshire Form Center -

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8wc.pdf Employer's First Report of Occupational Injury or Disease Form
8awca.pdf Notice of Accidental Injury or Occupational Disease
13wca.pdf Employer's Supplemental Report of Injury
NoticeofCompliance.pdf Notice of Compliance Information
9wca.pdf Memo of Payment of Disability Compensation
76wca.pdf Wage Schedule
76wca1.pdf Supplemental Wage Schedule
9wca1.pdf Memo of Denial of Workers' Compensation Benefits
75wca1.pdf NH Workers' Compensation Medical Form
10wca.pdf Memo of Permanent Impairment Award
74wca.pdf Report of Extended Disability
taxa.pdf NH Workers' Compensation Task Analysis
15wca.pdf Lump Sum Settlement Forms
wc3pr1.pdf Release and Settlement of Claim
14wca.pdf Authorization for Compensation for Death
witness.pdf Authorization to Permit Witness at Medical Examination
53wc.pdf Employee's Statement of Employment Status
53a.pdf Notice to Suspend Payment of Workers' Compensation Benefits
employee-leasing-checklist.pdf Employee Leasing Checklist
employee-leasing-initial.pdf Employee Leasing Initial Application
employee-leasing-renewal.pdf Employee Leasing Renewal Application
employee-leasing-bond.pdf Surety Bond for Employee Leasing Companies
si1.pdf Self-Insurance Application
sigroup.pdf Self Insurance Application-Group
gp.pdf Guarantee Proposal
si2.pdf Self-Insurance Surety Bond
si-q.pdf Self-Insurance Questionnaire
si4.pdf Certificate of Insurance
si-e.pdf Endorsement
si11.pdf Annual Financial Statement
si2a.pdf General Purpose Rider
ol.pdf Outstanding Liabilities
parent-company.pdf Parent Company Agreement
actuarial-summary.pdf Actuarial Opinion Summary Sheet
sda.pdf Securities Deposit Agreement
employee-information.pdf Employee Information Sheet
sif1.pdf Application for Second Injury Fund
SIF-Request.pdf Request for Reimbursement from the Second Injury Fund
SIF-Schedule.pdf Schedule of Reimbursable Payments
sif1a.pdf Second Injury Fund Affidavit of Employer Knowledge
sif1b.pdf Second Injury Fund Certification by Physician
9wca2.pdf Application for Reimbursement of Paid Adjusted Total Disability
9wca2comb.pdf Application for Reimbursement of Paid Combined Earnings
ACHEnrollmentForm.pdf State Treasury ACH Enrollment Form for Direct Deposits (ACH Credits)
wctpa.pdf Security Deposit Agreement for Third Party Administrator
coa.pdf Application for Certificate of Authority
noc.pdf Notice of Contract Between Third Party Administrator and Self Insurer
tpab.pdf Third Party Administration Bond
bioa.pdf Biographical Affidavit
jobmod.pdf Request for Job Modification Plan Approval
vr1.pdf Vocational Rehabilitation Provider Certification Form
iwrp.pdf Individual Written Rehabilitation Plan
vrt.pdf Vocational Rehabilitation Training Agreement
RehabClosure.pdf Rehabilitation Closure Form
RehabReferral.pdf Rehabilitation Referral Form
employee-contractor-poster.pdf POSTER - Criteria to Establish an Employee or Independent Contractor