Claims Forms

Workers' Compensation Identification Cards

General claim forms

Alabama

Claim Summary Form (WC 4) Supplementary Report (WC 3)
First Report of Injury (WCC 2) Travel Expenses Statement
Statement of Injured Wage Statement

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Arkansas

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

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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)
Florida Workers' Compensation Uniform Medical Treatment/Status Reporting Form with Instructions (DWC-25)
Formal Grievance Form
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)

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Georgia

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

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Indiana

Authorization to Disclose Health Info Travel Expenses
False or Fraudulent Claim Warining Treatment Plan
First Report of Injury Wage Statement
Statement of Injured  

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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)

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Louisiana

Authorization for Medical Records Report of Injury (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

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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)

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North Carolina

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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) Treatment Plan

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Tennessee

Employee's Choice of Physician (C-42) Statement of Injured
Employee's Choice of Physician (C-42) - Span. Travel Expenses Statement
First Report of Injury (C-20) Treatment Plan
Medical Waiver and Consent (C-31) Wage Statement (C-41)
Medical Waiver and Consent (C-31) - Span.  

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Texas

Authorization to Disclose Health Information
Beneficiary Claim For Death Benefits (DWC042)
Employers Wage Statement (DWC Form-003)
Notice of Injury (DWC Form-001)
Notice of IW Rights & Responsibilities in the Texas WC System
Request for Travel Reimbursement (DWC048)
Return to Work Reimbursement Program Flyer
Return to Work Reimbursement Program for Employers (DWC008)
Statement of Injured
Supplemental Report of Injury (DWC Form-006)

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