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List of Available Forms for Injured Workers


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® Link to External Website 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.

If a confirmation page does not appear in your web browser after you submit the form to the Board, then the Board did not successfully receive the form and you will need to resubmit it.

New Adobe adobe pdf Format Overview/Features

Instructions for Attaching Documents

Forms Submitted by Injured Workers
Form Number Form Title Registration required? Comments
C-3 Employee Claim No Must be filed within two years of injury, or within two years after employee knew or should have known that injury or illness was related to employment.
RFA-1W Request for Assistance By Injured Worker 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 FORM C-89.3.

Note:When filing required documents (e.g. medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder.
VDF-1 Loss of Wage Earning Capacity Vocational Data Form No Injured Workers who may have a non-schedule permanent impairment and who have not returned to work are encouraged to complete and submit Form VDF-1 as early as possible in the claim.

 

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.