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Workers’ Compensation Board

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Document Upload

Carrier Attorney/Insurer/TPA/Self-Insured Employer Forms Available For Upload

Form ID Description
C-107 EMPLOYERS Request for Reimbursement
C-240 Employer's Statement of Wage Earnings Preceding the Date of Accident
C-256.2 State Insurance Fund - Claim for Reimbursement of Wages Paid
C-258 Claimant's Record of Job Search
C-258.1 Injured Worker's Record of Independent Job Search Efforts
C-300.5 Stipulation
C-32 Settlement Agreement - Section 32
C-32.1 Claimant release form/Section 32
C-32-I Section 32 agreement -Indemnity only
C-4 Doctor's Initial Report
C-4.1 Continuation to Carrier/Employer Billing Portion of Form C-4
C-4.2 Doctor's Progress Report
C-4.3 Doctor's Report of MMI/Permanent Impairment
C-4/C-48 Attending Doctor's Report
C-4AMR Ancillary Medical Report
C-5 Attending Ophthalmologist's Report
C-62 Claim for Compensation in Death Case
C-64 Proof of Death by Physician Last in Attendance on Deceased
C-65 Proof of Burial and Funeral Expenses by Undertaker
CORR Correspondence
DEATH-CERT Death Certificate
EXHIBIT Exhibit (Medical or Other)
FCE-4 Practitioner's Report of Functional Capacity Examination
MED-NARR Medical Report
MEMO-OF-LAW Memorandum of Law
OT/PT4 Occupational/Physical Therapist's Report
PH-16.2 Pre-Hearing Conference Statement
PS-4 Psychologist's Report
REIB-REQUEST Reimbursement Request

Available Documents for Injured Workers/Claimants

Available Documents for Claimant Attorneys/Licensed Representatives

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