Home Contact us

Claims

Safety and Risk Management

Underwriting for Agents and CSRs

Back2Work
Claims
General claim forms
(These forms apply to all states. Check below for state-specific forms.)
Medical Questionnaire
Prescription Drug Program (First Prescription Fill—Letter of Intent)
OSHA 300 Log of Work-Related Injuries
OSHA 300a Summary of Work-Related Injuries
Alabama
Claim Summary Form (WC 4) Supplementary Report (WC 3)
First Report of Injury (WCC 2) Travel Expenses Statement
Statement of Injured Wage Statement
(Back to top)

Arkansas
First Report of Injury (IA-1) Travel Expenses Statement
Notice of Injury (AR-N) Wage Statement (AR-W)
Statement of Injured Workers' Comp Instructions (AR-P)
(Back to top)

Florida
Authorization and Request for Unemployment Compensation Information (DWC-30)
Employee Earnings Report (DWC-19)
False or Fraudulent Claim Warning
First Report of Injury (DWC-1)
Permanent Total Supplemental Worksheet (DWC-35)
Request for Social Security Disability Benefit Information (DWC-14)
Statement of Charges for Drugs and Medical Supplies (DWC-10)
Statement of Injured (FL only)
Statement of Quarterly Earnings (DWC-40)
Travel Expenses Statement
Wage Statement (DWC-1a)
(Back to top)

Georgia
Authorization to Release Info (WC-207) Notice of Payment (WC-2)
Case Progress Report (WC-4) Notice of Suitable Employment (WC-240)
First Report of Injury (WC-1) Statement of Injured
Job Analysis (WC-240A) Travel Expenses Statement
Medical Release (WC-104) Wage Documentation (WC-262)
Notice to Controvert (WC-3) Wage Statement (WC-6)
(Back to top)

Kentucky
False or Fraudulent Claim Warning Receipt of Managed Care Handbook
First Report of Injury (IA-1) Request for Payment/Reimbursement (114)
Grievance Review Request Statement of Injured
Medical Waiver and Consent (106) Treatment Plan
Notice of Designated Physician (113) Wage Certification (AWW-1)
(Back to top)

Louisiana
Authorization for Medical Records Report of Injury Instr. (LDOL-WC-1007)
Certificate of Compliance Statement of Injured
Final Cost Report (LDOL-WC-1003) Travel Expenses Statement
Notice of Payment (LDOL-WC-1002) Wage Statement
Report of Injury (LDOL-WC-1007)
(Back to top)

Mississippi
First Report of Injury (IAIBC-IA-1) Travel Expenses Statement
Notice of Final Payment (B31) Wage Statement
Statement of Injured Workers' Comp Commission (B18)
(Back to top)

North Carolina
Employer's Report of Employee Injury (Form 19)
Itemized Statement of Charges for Drugs (Form 25P)
Itemized Statement of Charges for Travel (Form 25T)
Notice of Accident and Claim (Form 18)
Statement of Days Worked and Earnings (Form 22)
Statement of Injured
(Back to top)

South Carolina
Authorization to Disclose Health Info Statement of Injured
First Report of Injury (Form 12-A) Travel Expenses Statement
Statement of Earnings (Form 20)  
(Back to top)

Tennessee
Employee's Choice of Physician (C-42) Statement of Injured
First Report of Injury (C-20) Travel Expenses Statement
Medical Waiver and Consent (C-31) Wage Statement
(Back to top)
 
© 2008 Summit. All rights reserved. Terms, Conditions, and Privacy Statement.
Summit includes Summit Consulting Inc. and its affiliates.