Claim Forms and Documents

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• DC Claim Forms
  • Form 7 Employee’s Notice of Accidental Injury or Occupation Disease
  • Form 7A Employee’s Claim Application
  • Form 8 Employer’s First Report of Injury or Occupational Disease
• FL Claim Forms
  • Form DWC-1 First Report of Injury or Illness
  • Form DWC 1a Wage Statement
  • Form DWC 3 Request for Wage Loss/Temporary Partial Benefits
• GA Claim Forms
  • Form WC-1 Employer’s First Report of Injury or Occupational Disease
  • Form WC-6 Wage Statement
  • Form WC-2 Notice of Payment or Suspension of Benefits
  • Form WC-104 Notice to Employee of Medical Release to Return to Work with Restrictions or Limitations
• MD Claim Forms
  • Form 1A-1 Workers Compensation – First Report of Injury or Illness
  • Form C-2 Statement of Wage Information
  • Form C-06 Insurer’s Termination of Temporary Total Disability Benefits
• MS Claim Forms
  • Form IAIABC IA-1 First Report of Injury or Illness
• NC Claim Forms
  • Form 19 Employer’s Report of Employees Injury or Occupational Disease to the Industrial Commission
  • Form 22 Statement of Days Worked and Earnings of Injured Employee
  • Form 25T Itemized Statement of Charges for Travel
  • Form 28 Return to Work Report
  • Form 28T Notice of Termination of Compensation by Reason of Trial Return to Work
• SC Claim Forms
  • Form 12A First Report of Injury or Illness
  • Form 20 Statement of Earnings of Injured Employee
• TN Claim Forms
  • Form C-20 Employer’s First Report of Work Injury or Illness
  • Form C-41 Wage Statement
  • Form C-42 Employee’s Choice of Physician
• VA Claim Forms
  • Form 3 Employer’s Accident Report
  • Form 7A Wage Chart