Web Submission of Medical Forms List of Available Forms

Forms submitted by attorneys and licensed representatives

Form Number	Form Title	Registration required?	Comments
PH-16.2	Pre-Hearing Conference Statement	No	Filed ten days before scheduled pre-hearing conference for controverted cases (FROI-04/SROI-04).
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.

 

Forms submitted by employers

Form Number	Form Title	Registration required?	Comments
C-11	Employer's Report of Injured Employee's Change in Employment Status Resulting From Injury	No	As soon as employment status of injured employee changes.
C-240	Employer's Statement of Wage Earnings	No	Within 10 days of request by the Board.
PH-16.2	Pre-Hearing Conference Statement	No	Filed ten days before scheduled pre-hearing conference for controverted cases (FROI-04/SROI-04).

 

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 Board assigns a WCB case number, or any time 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.
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.

 

Forms submitted by insurance carriers, self-insured employers,
and third-party administrators

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).

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.