| BWC # |
Form Title |
Price |
Buy Now |
| A-12 |
A.C.T. Enrollment and Direct Deposit Authorization |
$12.99 |
|
| A-21 |
Electronic Benefit Card |
$12.99 |
|
| A-35 |
Direct Deposit ACT Bank Change |
$12.99 |
|
| C-5 |
Addition In Formation for Death Benefits |
$12.99 |
|
| C-11 |
ADR Appeal to the MCO Medical Treatment/Service Decision |
$12.99 |
|
| C-17 |
Request for Injured Worker Outpatient Medication Reimbursement |
$12.99 |
|
| C-18 |
Wage Agreement |
$12.99 |
|
| C-23 |
Notice to Change Physician of Record |
$12.99 |
|
| C-30 |
Request for Medical In Formation |
$12.99 |
|
| C-32 |
Application for Payment of Lump Sum Advancement |
$12.99 |
|
| C-39 |
Annual Death Benefits Questionnaire |
$12.99 |
|
| C-59 |
Self-Insurer’s Agreement as to Compensation on Account of Death |
$12.99 |
|
| C-60 |
Completing the Injured Worker Statement for Reimbursement of Travel Expense |
$12.99 |
|
| C-60-A |
Injured Worker Reimbursement Rates for Travel Expense |
$12.99 |
|
| C-72 |
Authorization to Release In Formation |
$12.99 |
|
| C-77 |
Injured Worker’s Change of Address Notification |
$12.99 |
|
| C-84 |
Request for Temporary Total Compensation |
$12.99 |
|
| C-84-ES |
Request for Temporary Total Compensation (En Español) |
$12.99 |
|
| C-86 |
Motion |
$12.99 |
|
| C-86-ES |
Motion (En Español) |
$12.99 |
|
| C-92 |
Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability |
$12.99 |
|
| C-94-A |
Wage Statement |
$12.99 |
|
| C-101 |
Authorization to Release Medical In Formation |
$12.99 |
|
| C-108 |
Waiver of Appeal |
$12.99 |
|
| C-140 |
Initial Application for Wage Loss Compensation |
$12.99 |
|
| C-141 |
Wage Loss Statement for Job Search |
$12.99 |
|
| C-159 |
Waiver Of Workers’ Compensation Benefits For Recreational Or Fitness Activities |
$12.99 |
|
| C-230 |
Authorization to Receive Workers’ Compensation Check |
$12.99 |
|
| C-230-ES |
Authorization to Receive Workers’ Compensation Check (En Español) |
$12.99 |
|
| C-240 |
Settlement Agreement and Application for Approval of Settlement Agreement |
$12.99 |
|
| C-240-A |
Claimant’s Notice of Exception to Employer’s Signature Requirement |
$12.99 |
|
| C-241 |
Amended Settlement Agreement and Release |
$12.99 |
|
| C-255 |
Affidavit for Attorney Fees |
$12.99 |
|
| FROI |
First Report of an Injury, Occupational Disease or Death |
$12.99 |
|
| FROI-ES |
First Report of an Injury, Occupational Disease or Death (En Español) |
$12.99 |
|
|
Reporting fraud |
$12.99 |
|
| IC-167-T |
Objection to Tentative Order Awarding Permanent Partial Disability Compensation |
$12.99 |
|
| MEDCO-31 |
Request for Prior Authorization of Medication Form |
$12.99 |
|
| OD-58-22 |
Application for Adjustment of Claim in Case of Death Due to Occupational Disease |
$12.99 |
|
| R-2 |
Injured Worker Authorized Representative |
$12.99 |
|
| RH-1 |
Rehabilitation Agreement |
$12.99 |
|
| R-4 |
Application for Representative Identification Number |
$12.99 |
|
| RH-6 |
On-the-job Training Agreement |
$12.99 |
|
| RH-7 |
Loan/Release Agreement for Tool and Equipment |
$12.99 |
|
| RH-10 |
Vocational Rehabilitation Plan Job Search Contacts |
$12.99 |
|
| RH-18 |
Authorization for Living Maintenance Wage Loss |
$12.99 |
|
| RH-24 |
Gradual Return to Work Agreement |
$12.99 |
|
| SH-6 |
PERRP Complaint Form |
$12.99 |
|
| SI-28 |
Filing of Allegation Against a Self-Insured Employer |
$12.99 |
|
| SI-42 |
Self Insured Joint Settlement Agreement and Release |
$12.99 |
|
| SI-43 |
Acknowledgement of the Self-Insured Joint Settlement Agreement and Release |
$12.99 |
|
|
Subrogation Referral Form |
$12.99 |
|
