These forms are available for completion and online submission through the Board's website. To access a form, select the form number or title. If registration is required, a login screen will prompt you for your user ID and password. Complete the online application to register for Web Submission of Claim Forms.
After the Board receives your form, a non-editable PDF version of the form will appear in your web browser. The first page contains a confirmation that your form was successfully submitted to the Board and the date. It should be saved for your records. DO NOT MAIL THIS FORM TO THE BOARD.
Form Number | Form Title | Registration required? | Comments |
---|---|---|---|
C-8.1B| | Notice of Objection to a Payment of a Bill for Treatment Provided | Yes | Treatment issue: within 5 days after terminating medical care or refusing authorization. Disputed bill: within 45 days of submission of bill. |
DB-470| | Preliminary/Final Claim for Reimbursement of Benefits Paid Under Disability Benefits Law | Yes | Submitted prior to award of workers' compensation benefits. |
PH-16.2 | Pre-Hearing Conference Statement | No | Filed ten days before scheduled pre-hearing conference for controverted cases (FROI-04/SROI-04). |
RFA-2| | Request for Further Action By Carrier/Employer | No | The form may be filed at any time after the indexing of a claim or after the Board has indicated that no further action (NFA) will
be taken.
Note: When filing required documents (e.g. medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder. |
If the form you are looking for is not available for online submission, you may print the PAPER version of the form from our list of common forms.