List of Available Forms for Carriers, Self Insured Employers and Third Party Administrators
These forms are available for completion and online submission through the Board's web site.
The forms uses Adobe Reader to render the form. Adobe Reader® 9 or later, is recommended to support the additional functionality in this form. The latest version of Adobe Reader® is available as a free download from Adobe's web site.
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.
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Complete the online application to register for Web Submission of Claim Forms.
|Form Number||Form Title||Registration required?||Comments|
|C-2|||Employer's Report of Work-Related Injury/Illness||No||Must be filed within ten days after occurrence of accident.|
|C-7|||Notice that Right to Compensation is Controverted||Yes||Must be filed on or before 18th day after disability or within 10 days after employer had knowledge of injury, whichever is greater.|
|C-8/8.6|||Notice that Payment of Compensation has been Stopped or Modified||Yes||Must be filed within 16 days after the date on which benefit payments were stopped or modified.|
|C-8.1|||Notice of Treatment Issue(s)/ Disputed Bill Issue(s)||Yes||Treatment issue: within 5 days after terminating medical care or refusing authorization.
Disputed bill: within 45 days of submission of bill.
|C-669|||Notice to Chair of Carrier's Action on Claim for Benefits||Yes||IF PAYMENT HAS BEGUN: must be filed on or before 18th day
after disability, or within 10 days after employer first had knowledge of
injury, whichever is greater.
IF PAYMENT HAS NOT BEGUN: no later than 25 days after the Board has mailed a Notice of Indexing.
|DB-470|||Preliminary/Final Claim for Reimbursement of Benefits Paid Under Disability Benefits Law||Yes||Submitted prior to award of workers' compensation benefits.|
Adobe Format Overview/Features
|Pre-Hearing Conference Statement||No||Filed ten days before scheduled pre-hearing conference for controverted (C-7) cases.|
|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. REPLACES FORMS C-89.3, C-22B, CB-8 AND RB-679.
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.