| Form | Description | DOC | Fee | |
|---|---|---|---|---|
| Form 12A | First Report of Injury | Doc | No fee | |
| Form 12M | Annual Minor Medical Report | Doc | No fee | |
| Form 14A | Health Insurance Claim Form | Word Format not Available |
No fee | |
| Form 14B | Physician's Statement | Doc | No fee | |
| Form 15 | Temporary Compensation Report | Doc | $50.00 for Section III only |
|
| Form 15S | Supplemental Report of Varying Temporary Partial Payments |
Doc | No fee | |
| Form 16 | Agreement for Permanent Disability/Disfigurement Compensation |
Doc | $50.00 if filed by Claimant's Attorney |
|
| Form 16A | Agreement for Permanent Disability/Disfigurement Compensation Please complete this form for injuries occurring after July 1, 2007 |
Doc | $50.00 if filed by Claimant's Attorney |
|
| Form 17 | Receipt of Compensation | Doc | No fee | |
| Form 18 | Periodic Report | Doc | No fee | |
| Form 19 | Saturation Report and Compensation Report | Doc | No fee | |
| Form 20 | Statement of Earnings of Injured Employee | Doc | No fee | |
| Form 24 | Application for Lump Sum Award | Doc | $50.00 | |
| Form 50 | Employee's Notice of Claim and or Request for Hearing |
Doc | $50.00 for Request for Hearing only |
|
| Form 52 | Employee's Notice of Claim and/or Request for Hearing, Death Case |
Doc | $50.00 for Request for Hearing only |
|
| Form 53 | Employer's Answer to Request for Hearing, Death, Case |
Doc | No Fee | |
| Form 61 | Attorney Fee Petition | Doc | No fee | |
| Form S-1 | Notice of Third Party Action Employee Carrier | Doc | No fee | |
| Form S-2 | Notice of Third Party Action Employee | Doc | No fee |
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