| WordMill Form Sets & Contents | Last updated 8/2/2018 3:49:29 PM |
| Alabama Workers' Comp. version 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Combination Supplementary & Claim Summary Form | 2/15/2001 | WC Form 2 Employer's First Report of Injury or Occupational Disease | 9/1/2006 | WC Form 3 Supplementary Report | 1/1/1993 | WC Form 4 Claim Summary Form | 5/1/1995 | Arizona Workers' Comp. version 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | ICA 04-0101 Employer's Report of Industrial Injury | 7/1/2001 | ICA 04-0102 76 Worker's & Physician's Report of Injury | 1/1/1992 | ICA 04-0103 80 Notice of Supportive Medical Maintenance Benefits | 1/1/1994 | ICA 04-0104A Notice of Claim Status | 1/1/1994 | ICA 04-0105-80 Notice of Suspension of Benefits | 6/1/1998 | ICA 04-0106-80 Notice of Permanent Disability or Death Benefits | 1/1/1994 | ICA 04-0108-75 Recommended Average Monthly Wage Calculation of Carrier | 1/1/1994 | ICA 04-0110-A Worker's Annual Report of Income | 1/1/1994 | ICA 04-0110-B Notice of Intent to Suspend | 1/1/1994 | ICA 04-0407 Worker's Report of Injury | 5/1/2002 | ICA 04-0446-75 Request for Hearing | 5/1/2002 | ICA 04-0528-83 Petition to Reopen Based on New, Additional or Previously Undiscovered Disability or Condition | 5/1/2002 | ICA 04-0529-71 Petition for Rearrangement or Readjustment of Compensation | 5/1/2002 | ICA 04-10786 Notice of Permanent Disability and Request for Determination of Benefits | 1/1/1993 | Request to Change Doctors | 8/1/2007 | California Workers' Comp. version 2.7.7 CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | DIA 510 Notice of Employee Death | 3/1/1984 | DIA WCAB Form 2 Application for Adjudication of Claim - Death Case | 7/1/1981 | DIA WCAB Form 30 Subpoena | 6/1/1994 | DIA WCAB Form 32 Subpoena Duces Tecum | 6/1/1994 | DIA WCAB Form 42 Petition to Reopen | 8/1/1985 | DIA WCAB Form 43 Request for Dismissal | 11/1/1974 | DIA WCAB Form 49 Petition for Commutation of Future Payments | 11/1/1974 | DIA WCAB Form 51 Order of Dismissal | 12/1/1975 | DIA WCAB Form 65 Order Approving Compromise and Release | 5/1/1975 | DWC Form 1 Employee's Claim for Workers' Comp. Benefits | 6/1/2010 | DWC Form 3 Disclosure Statement | 3/1/1993 | DWC Form RB-105 Request for Conclusion of Rehabilitation Benefits | 1/1/2003 | DWC Form RB-105 Instructions | 1/1/2003 | DWC Form RU-101 Case Initiation Document | 12/1/1990 | DWC Form RU-101 Documento Para Iniciar el Caso | 12/1/1990 | DWC Form RU-103 Request for Dispute Resolution | 1/1/2003 | DWC Form RU-103 Instructions | 1/1/2003 | DWC Form RU-104 Employee Request for Order of Vocational Rehabilitation Services | 12/1/1990 | DWC Form RU-105 Notice of Termination of Vocational Rehabilitation Services | 1/1/2003 | DWC Form RU-105 Instructions | 1/1/2003 | DWC Form RU-107-A Declaracion del Empleado de Rechazo de Servicios Vocacionales de Rehabilitacion | 1/1/1994 | DWC Form RU-107-A Employee Statement of Declination of Vocational Rehabilitation Services | 1/1/1994 | DWC Form RU-122 Settlement of Prospective Vocational Rehabilitation Services | 11/1/2008 | DWC Form RU-122 Settlement of Prospective Vocational Rehabilitation Services Instructions | 11/1/2008 | DWC Form RU-90 Informe del Medico Sobre la Condicion de Incapacidad | 12/1/1990 | DWC Form RU-90 Treating Physician's Report of Disability Status | 12/1/1990 | DWC Form RU-91 Description of Employee's Job Duties | 2/1/1995 | DWC Form RU-91 Instructions | 2/1/1995 | DWC WCAB Form 1 Application for Adjudication of Claim | 11/1/2008 | DWC WCAB Form 1 Instructions | DWC WCAB Form 10 Workers' Compensation Appeals Board Answer | 7/1/1981 | DWC WCAB Form 36 Substitution of Attorneys | 10/1/1974 | DWC WCAB Form 37 Notice of Dismissal of Attorney | 8/1/1990 | DWC WCAB Form 45 Petition for Reconsideration | 3/1/1976 | DWC WCAB Form 5 Stipulation and Award and/or Order | 10/1/2005 | DWC WCAB Form 8 Petition for Appointment of Guardian ad Litem and Trustee | 10/1/1990 | DWC-AD Form 100 Employee's Disability Questionnaire | 11/1/2008 | DWC-AD Form 101 Request for Summary Rating Determination | 11/1/2008 | DWC-AD Form 102 Request for Summary Rating Determination | 11/1/2008 | DWC-AD Form 103 Request for Reconsideration of Summary Rating | 11/1/2008 | DWC-AD Form 104 Request for Consultative Rating | 11/1/2008 | DWC-CA Form 10118 Notice of Offer of Regular Work | 11/1/2008 | DWC-CA Form 10133 Notice of Offer of Modified or Alternate Work | 11/1/2008 | DWC-CA form 10214(a) Stipulations With Request for Award | 11/1/2008 | DWC-CA Form 10214b Stipulations With Request for Award - Death Case | 11/1/2008 | DWC-CA Form 10214c Compromise and Release | 11/1/2008 | DWC-CA Form 10214d Compromise and Release - Dependency Claim | 11/1/2008 | DWC-CA form 10232.1 Document Cover Sheet | 7/1/2010 | DWC-CA form 10232.2 Document Separator Sheet | 9/1/2010 | DWC-CA Form 10250 Declaration of Readiness to Proceed | 7/1/2010 | DWC-CA Form 10252 Request for Expedited Hearing and Decision | 11/1/2008 | Form 160 Request for Qualified Medical Evaluator | 4/14/2000 | Form 160 Request for Qualified Medical Evaluator (Spanish) | 1/1/1997 | Form 180 Request Pertaining To Military Records | 3/1/1999 | Form 5021 Doctor's First Report of Occupational Injury or Illness | 4/1/1992 | Form SCIF 3067 Employer's Report of Injury or Illness | 2/1/1993 | IRS 4506 Request for Copy of Tax Form | 5/1/1997 | Longshore Claims Records | Medical Records | no form name available | 6/1/2010 | Prior Employment Records | Social Security Disability Records | SSA-7050-F3 Request for SSA Earnings Info | 10/1/1986 | Veterans Administration Records | WCAB Form 30A Pre-Application Discovery Order | 2/1/1991 | WCAB Form 31 Petition for Order Allowing Pre-Application Attorney Fee and Order | 2/1/1991 | Colorado Workers' Comp. version 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Form WC-1 Employer's First Report of Injury | 1/1/2006 | Form WC-1-A Average Weekly Wage Worksheet (auto) | 10/1/1995 | Form WC-1-A Average Weekly Wage Worksheet (manual) | 10/1/1995 | Form WC-12 Supplemental Report of Accident | 7/1/2003 | Form WC-145 Final Admission of Liability (auto) | 12/1/2001 | Form WC-146 Notice and Proposal to Select an Independent Medical Examiner | 1/1/2006 | Form WC-151 Fatal Case - General Admission | 5/1/2005 | Form WC-152 IME Strike Fax Form | 10/1/1998 | Form WC-153 Fatal Case - Final Admission | 6/1/2005 | Form WC-17 Election of Remedies | 7/1/1996 | Form WC-2 General Admission of Liability (auto) | 7/1/2007 | Form WC-2 General Admission of Liability (manual) | 7/1/2007 | Form WC-20 Admission - Fatal Case | 5/1/1998 | Form WC-25 Final Payment Notice | 1/1/2006 | Form WC-4 Final Admission of Liability | 8/1/2003 | Form WC-54 Petition to Modify, Terminate, or Suspend Compensation | 1/1/2006 | Form WC-55 Objection to Petition to Modify, Terminate, or Suspend Compensation | 5/1/2005 | Form WC-62 Application for Lump Sum | 6/1/2007 | Form WC-74 Notice of Contest | 6/1/2005 | Form WC-77 Application For a Division Independent Medical Examination | 5/1/2005 | Gallagher Bassett Letter | 10/1/1998 | Connecticut Workers' Comp. 2.7.6 b CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Form 1A Filing Status and Exemption Form | 4/1/2003 | Form 30C Notice of Claim for Compensation | 10/20/2001 | Form 36 Notice to Discontinue or Reduce Payments | 1/1/2005 | Form 42 Physicians's Report of Medical Evaluation | 1/31/2005 | Form 43 Notice of Intention to Contest Liability to Pay | 7/22/2002 | Form 6B Coverage Selection for Officer of Corp. | 1/15/2004 | Form 6B1 Coverage Selection for Members of Partnership | 1/15/2004 | Form 75 Notice of Intention to Contest Liability to Pay | 1/15/2004 | Form HR Hearing Request | 10/20/2001 | Florida Workers' Comp. version 2.7.6 b CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Form G-1 Response to Petition for Benefit | LES Form DWC-1 First Report of Injury or Illness | 3/1/2009 | LES Form DWC-10 Statement of Charges for Drugs and Medical Supplies | 3/1/2004 | LES Form DWC-12 Notice of Denial | 3/1/2009 | LES Form DWC-13 Claim Cost Report | 3/1/2009 | LES Form DWC-14 Request for Social Security Disability Benefit Information | 3/1/2009 | LES Form DWC-19 Employee Earnings Report | 3/1/2009 | LES Form DWC-1A Wage Statement | 3/1/2009 | LES Form DWC-25 Uniform Medical Treatment/Status Reporting Form | 8/1/2004 | LES Form DWC-3 Request for Wage Loss/Temporary Partial Benefits | 8/1/2004 | LES Form DWC-30 Authorization and Request for Unemployment Compensation Information | 3/1/2009 | LES Form DWC-33 Permanent Total Off-Set Worksheet | 3/1/2009 | LES Form DWC-35 Permanent Total Supplemental Worksheet | 3/1/2009 | LES Form DWC-4 Notice of Action/Change | 3/1/2009 | LES Form DWC-40 Statement of Quarterly Earnings for Supplemental Income Benefits | 3/1/2009 | LES Form DWC-48 Monthly Risk Class/SIC Code Report | 11/1/1994 | LES Form DWC-49 Aggregate Claims Administration Change Report | 3/1/2009 | LES Form DWC-51 Aggregate Defense Attorney Fee Report Instructions | LES Form DWC-8 Notification of Initial Treatment | 9/1/1994 | LES Form DWC-9A Maximum Medical Improvement/Permanent Impairment Determination Certification Form | 6/1/1996 | Georgia Workers' Comp. version 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Subpoena | 1/1/2013 | WC-1 Employer's First Report of Injury or Occupational Disease | 7/1/2011 | WC-1 Employer's First Report of Injury or Occupational Disease - Additional Sheet for Controversion | 7/1/2003 | WC-10 Notice of Election or Rejection of Workers' Compensation Coverage | 5/1/2013 | WC-102 Request for Documents to Parties | 7/1/2011 | WC-102b Notice of Representation of any Party other than a Claimant or Employee By an Attorney | 7/1/2011 | WC-102c Attorney Leave of Absence | 7/1/2011 | WC-102d Motion / Objection to Motion | 7/1/2014 | WC-104 Notice to Employee of Medical Release to Return to Work With Restrictions or Limitations | 1/1/2014 | WC-108a Attorney Fee Approval | 7/1/2011 | WC-108b Attorney Withdrawal/Lien | 7/1/2011 | WC-12 Request for Copy of Board Records | 7/1/2011 | WC-121 Notice of Use of Servicing Agent | 7/1/2014 | WC-14 Notice of Claim / Request for Hearing / Request for Mediation | 7/1/2011 | WC-2 Notice fo Payment or Suspension of Benefits | 7/1/2015 | WC-200a Change of Physician/Additional Treatment by Consent | 7/1/2011 | WC-200b Request/Objection for Change of Physician/Additional Treatment | 7/1/2014 | WC-206 Notice of Intent to Become a Party at Interest | 7/1/2014 | WC-207 Authorization and Consent to Release Information | 7/1/2011 | WC-20a Medical Report | 7/1/2011 | WC-240 Notice to Employee of Offer of Suitable Employment | 7/1/2014 | WC-243 Credit/Reduction in Benefits | 7/1/2011 | WC-244 Notice of Intent to Become a Part of Interest | 7/1/2014 | WC-25 Application for Lump Sum/Advance Payment | 7/1/2014 | WC-26 Consolidated Yearly Report of Medical Only Casese | 7/1/2014 | WC-2a Notice of Payment or Suspension of Death Benefits | 7/1/2015 | WC-3 Notice to Controvert | 7/1/2011 | WC-4 Case Progress Report | 7/1/2011 | WC-6 Wage Statement | 7/1/2011 | WC-R1 Request for Rehabilitation | 7/1/2011 | WC-R2 Rehabilitation Transmittal Form | 7/1/2011 | WC-R2a Individualized Rehabilitation Plan | 7/1/2011 | WC-R3 Request for Rehabilitation Closure | 7/1/2013 | Illinois Cook County Civil Court Forms 2.7.5 CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Affidavit As to Military Service (CCG-4) | 8/26/1992 | Affidavit for Garnishment (Non-Wage) (CCL-24) | 4/1/1981 | Affidavit for Service by Publication (CCG-13) | 2/1/1981 | Affidavit for Wage Deduction Order (CCM1-133) | 4/18/1994 | Answer to Citation Proceeding (CCM1-128) | Appearance and Jury Demand (CCG-9) | 3/1/1981 | Attachment Bond (CCG-72) | 6/1/1982 | Certificate of Mailing Citation (CCG-0643) | 11/23/1993 | Citation Notice (CCG-0648) | 11/18/1993 | Citation to Discover Assets (CCG-5) | 11/18/1993 | Garnishment (Non-Wage) Notice (CCG-0646) | 11/19/1993 | IRS 4506 Request for Copy of Tax Form | 5/1/1997 | Jury Demand (CCG-67) | 2/1/1981 | Memorandum of Judgment (CCG-15) | 4/1/1986 | Motion General Form (CCMD-39) | 4/1/1981 | Notice of Hearing for the Issuance of An Order of Replevin (CCM1-62) | 6/1/1982 | Order (CCG-81) | 5/1/1982 | Order for Possession (CCM1-0114) | 2/15/1996 | Order to Dismiss by Stipulation (CCM-1-121) | 1/1/1985 | Release (Satisfaction) of Judgment (CCG-8) | 4/1/1981 | Release Medicals | Release Prior Employers | Release SSA | Release VA | Satisfaction Release of Judgment (CCG-8A) | 9/13/1995 | Stipulation for Installment Payments of Judgment and Costs (CCM1-92) | 2/1/1985 | Stipulation to Dismiss Action (CCM-1-117) | 1/1/1985 | Subpoena (CCG-6) | 12/1/1988 | Subpoena for Deposition (CCG-14) | 6/20/1994 | Summons (CCG-1) | 3/21/1995 | Summons After Conditional Judgment (CCMI-26B) | 11/12/1992 | Wage Deduction Notice (CCM1-129A) | 12/1/1991 | Illinois Cook County Domestic and Probate Forms 2.7.5 CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Affidavit of Joint Petition for Simplified Divorce | Appearance (Domestic) | 4/22/1996 | Application for Child Support Enforcement Services | 1/1/1996 | Application to Proceed Under Supreme Court Rule 298 | 2/1/1994 | Asset Disclosure Statement | 5/2/1996 | Case Management Order | 4/26/1996 | Certification and Agreement by Counsel | 6/7/1996 | Copy of Will | 6/1/1989 | Domestic Relations Cover Sheet | 6/23/1995 | Financial Disclosure Statement | 5/2/1996 | IRS 4506 Request for Copy of Tax Form | 5/1/1997 | Judgment for Joint Simplified Dissolution of Marriage | 1/1/1994 | Motion and Order to Vacate Dismissal Within Thirty Days | 7/1/1991 | Motion for Appointment of Special Process Server | 10/1/1991 | Notice of Motion, Wage Deduction Exemption Hearing | 3/12/1992 | Notice to Heirs and Legatees | 1/27/1997 | Oath and Bond of Representative - No Surety | 7/25/1995 | Oath and Bond of Representative - Surety | 6/1/1989 | Order | 5/1/1982 | Order Admitting Will to Probate and Appointing Representative | 6/1/1989 | Order Declaring Heirship | 6/26/1996 | Order of Commitment | 3/24/1993 | Order to Suspend Driving Privileges | Order, Focus on Children | 12/19/1994 | Orders of Continuance, Transfer and Dismissal | 4/25/1996 | Petition for Letter of Administration to Collect | 8/20/1993 | Petition for Probate of Will and for Letters Testamentary | 6/1/1989 | Petition to Convert to Independent Administration | 7/20/1993 | Praecipe for Divorce | 3/30/1993 | Release of Estate's Interest in Real Estate | 12/28/1992 | Stipulation and Request to Hear Uncontested Cause in Suburban District | 6/1/1989 | Subpoena | 12/1/1988 | Subpoena for Deposition | 6/20/1994 | Summons | 3/21/1995 | Waiver of Notice Probate | 1/1/1992 | Illinois Workers' Comp. 2.7.6 b CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | A-10 Attorney Representation Agreement Workers' Compensation/Occupational Disease | 7/1/1991 | DC Disputed Claim | 6/1/1981 | Form 45 Employer's First Report of Injury or Illness | 1/1/2000 | IC-1 Application for Adjustment of Claim | 6/1/1999 | IC-11 Petition for Review of Decision of Arbitrator and Order for Transcript | 6/1/1999 | IC-11A Petition for Review of §19(b-1) Decision of Arbitrator | 2/1/1993 | IC-14 Petition for Review of Agreement or Award Under §19(h) and/or §8(a) and Transcript Order Form | 6/1/1999 | IC-14A Petition for Immediate Hearing Under §19(b-1) | 8/1/1984 | IC-14B Response to Petition for Immediate Hearing Under Petition for Immediate Hearing Under §19(b-1) | 10/1/1984 | IC-16 Subpoena | IC-17 Motion / Order | IC-33 Dedimus Potestatem | 6/1/1988 | IC-4 Notice of Motion and Order | 6/1/1999 | IC-5 Settlement Contract Lump Sum Petition and Order | 12/1/1999 | IC-6 Appearance of Representative | 8/1/1991 | IC-7 Petition for Immediate Hearing | 6/1/1999 | IC-8 Response to Petition for Immediate Hearing | 6/1/1999 | IC-85 Employer's Supplementary or Final Report of Injury or Illness | 6/1/1990 | ICRP Rehabilitation Plan | 5/1/1988 | IL 563-0010 Substitution of Attorneys | IL 563-0032 Motion to Dismiss Attorney of Record | NED By Stipulation - Nature and Extent In Dispute | RSF-1 Review Proceedings Stipulation Form | 1/1/1986 | SA Request for Hearing | 10/1/1981 | Indiana Workers' Comp. 2.7.6 b CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Form 1042 Application for Review by Full Board | 9/1/1991 | Form 1043 Agreement to Compensation of Employee and Employer | 5/1/1988 | Form 18487 Application for Adjustment of Claim for Provider Fee | 8/1/1995 | Form 18875 Agreement to Compensation Between the Dependents of Deceased Employee and Employer | 9/1/1987 | Form 2118 Report of Attending Physician | 9/1/1991 | Form 29109 Application for Adjustment of Claim | 3/1/1995 | Form 34401 First Report of Employee Injury/Illness | 2/1/1996 | Form 34873 Agreement Between Parties for Lump Sum | 10/1/1987 | Form 34877 Subpoena | 10/1/1993 | Form 38911 Report of Claim Status / Request for Independent Medical Examination | 9/1/1991 | IRS 8038 Series version 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$129.00 | Form Names: | Rev: | 8038 Information Return for Tax-Exempt Private Activity Bond Issues | 4/1/2011 | 8038 Instructions | 4/1/2011 | 8038-B Information Return for Build America Bonds and Recovery Zone Economic Development Bonds | 1/1/2010 | 8038-CP Return for Credit Payments to Issuers of Qualified Bonds | 1/1/2012 | 8038-G Information Return for Tax-Exempt Governmental Obligations | 9/1/2011 | 8038-GC Information Return for Small Tax-Exempt Governmental Bond Issues, Leases, and Installment Sales | 1/1/2012 | 8038-GC Instructions | 1/1/2012 | 8038-R Instructions | 4/1/2011 | 8038-R Request for Recover of Overpayments Under Arbitrage Rebate Provisions | 4/1/2011 | 8038-T Abritrage Rebate and Penalty in Lieu of Arbitrage Rebate | 4/1/2011 | 8038-T Instructions | 4/1/2011 | 8038-TC Information Return for Tax Credit Bonds and Speficied Tax Credit Bonds | 11/1/2012 | 8038-TC Information Return for Tax Credit Bonds and Speficied Tax Credit Bonds Schedules | 11/1/2012 | Louisiana - Jefferson Parish Civil Court version 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$129.00 | Form Names: | Rev: | 24th Judicial District Subpoena Duces Tecum | 1/1/2009 | 24th Judicial District Subpoena Request | 5/13/2002 | Addendum page | Application for Pro Hac Vice Admission in Louisiana | Authorization to Release Medical Records | Authorization to Release Prior Employment Records | Authorization to Release Social Security Disability Records | Authorization to Release Veterans Records | Commissioner of Insurance Reporting Form | First Parish Court - Affidavit of Correctness of Account | 6/3/2002 | First Parish Court - Certification of Attorney | 6/3/2002 | First Parish Court - Garnishment Interrogatories and Order | 6/3/2002 | First Parish Court - Judgment | 6/3/2002 | First Parish Court - Motion and Order for a New Trial on a Judgment of Eviction | 6/3/2002 | First Parish Court - Motion for Writ of Attachment for Arrest | 6/3/2002 | First Parish Court - Motion to Set Trial | 6/3/2002 | First Parish Court - Motion to Withdraw Garnishee Fee | First Parish Court - Recall of Attachment or Capias | 6/3/2002 | First Parish Court - Subpoena Duces Tecum | 6/28/2002 | Hearing Officer Conference Affidavit | IRS 4506 Request for Copy of Tax Form | 9/1/2013 | Jefferson Parish Financial Statement | Mediation Cover Sheet | Motion to Set For Trial on the Merits | 12/3/2003 | Motion to Set Trial on the Merits Divorce | Order of Consolidation | 12/17/2002 | Order of Transfer | 12/17/2002 | Request for Attachment | 12/1/2000 | Second Parish Court - Judgment | 6/3/2002 | Second Parish Court - Motion to Set Trial | 6/3/2002 | Second Parish Court - Subpoena | 10/23/2002 | Second Parish Court - Subpoena Duces Tecum | 10/23/2002 | Second Parish Court - Subpoena for Deposition | 10/23/2002 | Subpoena (Deposition Subpoena - WordMill Enhanced) | Louisiana - Orleans Parish Civil Court version 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$129.00 | Form Names: | Rev: | Affidavit of Non-Military Service | Authorization to Release Medical Records | Authorization to Release Prior Employers' Records | Authorization to Release Social Security Records | Authorization to Release Veterans Records | Clerk of Civil District Court Cover Sheet | Cover Sheet - All Actions for Divorce or Annulment | Form 1004 First City Court Subpoena | 4/1/2000 | Form 1007 First City Court Judgment | Form 1020 First City Court Summons | Form 1022 First City Court Affidavit | Form 1036 First City Court Service of Notice of Trial | Form 1036A Motion to Set For Trial on the Merits | Form 1038 First City Court Affidavit of Correctness of Account and/or Not and Non-Military Service | Form 1047 First City Court Subpoena Duces Tecum | 4/1/1989 | Form 1047 First City Court Subpoena Duces Tecum | 4/1/1989 | Form 1047 Second City Court Subpoena Duces Tecum | 4/1/1995 | Form 1098 First City Court Citation of Appeal | Form 15 Garnishment Interrogatory | Form 16 Letters | Form 20 Succession Order | 7/1/1999 | Form 37 Motion for Default | Form 46 Request for Writ of Fieri Facias | Form 47 Succession Notice to Publish | 1/1/1983 | Form 52 First City Court Subpoena | 4/1/1989 | Form 52 Second City Court Subpoena | 4/1/1989 | Form 54 Oath | Form 7A Judgment | Form 7A Judgment by Default | Form 94 Appeal | Form 95 Sheriff's Return | Hippa Complient Medical Authorization | In Forma Pauperis Affidavit (page 1-2) | IRS 4506 Request for Copy of Tax Form | 9/1/2013 | Jury Trial Order | Letters Testamentary | Motion to Set for Trial | Motion to Set Hearing | Orleans Parish Monthly Income and Expense List | Request for Attachment | 12/1/2000 | Request for Records Stored Offsite | 11/10/2009 | SSA-7050-F4 Request for SSA Earnings Info | 1/1/2014 | Statement of Income and Expense / Alimony after Divorce | Subpoena | 9/1/2011 | Supreme Court Writ Application Filing Sheet | Louisiana Dept. of Motor Vehicles 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$129.00 | Form Names: | Rev: | Act of Donation | Affidavit | Affidavit of Error | Affidavit of Heirship | 8/1/2002 | Affidavit of Identity | Affidavit of Non-Use of Vehicle | Affidavit of Roadworthy | Affidavit of Sale at Less Than Book Value | Bill of Sale | Disclosure of Reconstructed Vehicle | Disclosure of Salvaged Vehicle | Disclosure of Water Damaged Vehicle | Notes | Odometer Statement | Power of Attorney | Statement of Residency | Summary Sheet | Vehicle Application DPSMV 1799 | 1/1/2012 | Louisiana Fidiciary Tax 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
Form Names: | Rev: | Fiduciary Return | 10/1/2001 | Louisiana Gift Tax 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
Form Names: | Rev: | Gift Tax 709 | 8/1/2002 | Louisiana Inheritance Tax version 2.7.6 b CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Affidavit of Small Succession | 4/1/2002 | IETT-100 Instructions | 7/1/2005 | Inventory List | LA Inheritance and Estate Heirs Attachment | 1/1/1998 | LA Inheritance and Estate Transfer Tax Return | 2/1/2004 | Louisiana UCC version 2.7.6 b CLICK HERE TO DOWNLOAD / INSTALL |
$129.00 | Form Names: | Rev: | Attachment Sheet | UCC-1 Financing Statement | 11/22/2010 | UCC-1 Instructions | 11/22/2010 | UCC-11 Instructions | 5/9/2001 | UCC-11 Request for Information or Copies | 5/9/2001 | UCC-1F Financing Statement for Farm Products | 2/14/2012 | UCC-1F Instructions | 2/14/2012 | UCC-2F Attachment | 1/1/1992 | UCC-3 Instructions | 5/4/2011 | UCC-3 Statements of Continuation, Release, Assignment, Etc. | 5/4/2011 | UCC-3F Continuation, Release, Assignment, Etc. for Farm Products | 12/29/2011 | UCC-3F Instructions | 12/29/2011 | UCC-5 Correction | 7/19/2012 | UCC-5 Instructions | 7/19/2012 | Louisiana Workers' Comp. version 2.7.6 b CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Affidavit - Defendant's Atty | Affidavit - Plaintiff's | Affidavit - Plaintiff's Atty's | Claim Data Form | HR14 Claim Petition Answer | LDOL-WC-1007 Instructions | 1/1/1998 | Longshore Claims Records | LWC Form 1010A - First Request | LWC-IA-1 Instructions | 1/1/2013 | LWC-IA-1 Workers Compensation - First Report of Injury or Illness | 1/1/2013 | LWC-WC-1002 Notice of Payment | 1/1/2014 | LWC-WC-1003 Final Cost Report | 7/1/2008 | LWC-WC-1004 Request for Social Security Benefits Information | 7/1/2008 | LWC-WC-1005A Motion for Recognition of Right to Social Security Offset | 7/1/2008 | LWC-WC-1007 Employer Report of Injury/Illness | 7/1/2008 | LWC-WC-1008 Disputed Claim for Compensation | 2/1/2009 | LWC-WC-1009 Disputed Claim for Medical Treatment | 11/1/2012 | LWC-WC-1010 Notice of Payments to Dependants for Death | 1/1/1987 | LWC-WC-1011 Request for Compromise or Lump Sum Settlement | 1/1/1998 | LWC-WC-1015 Request for Independent Medical Examination | 7/1/2008 | LWC-WC-1020 Employee's Monthly Report of Earnings | 7/1/2008 | LWC-WC-1025.EE Employee Certificate of Compliance | 7/1/2008 | LWC-WC-1025.ER Employer Certificate of Compliance | 7/1/2008 | LWC-WC-1026 Employee's Quarterly Report of Earnings | 7/1/2008 | LWC-WC-1027 Request for Waiver of Payment of Advance Costs | 1/1/1998 | Medical Records | Minimum and Maximum Rates of Compensation | 7/1/2003 | Prior Employment Records | Social Security Disability Records | Subpoena and Subpoena Duces Tecum | Subpoena Duces Tecum for Inspection | Subpoena for Deposition and Subpoena Duces Tecum | Verification - Attorneys | Veterans Administration Records | Massachussetts Workers' Comp. version 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Affidavit In Support of Request for Waiver of Filing Fee Under s.11C | 7/1/2013 | Agreement to Extend 180 Day Payment Without Prejudice Period | 7/1/2013 | Form 101 Employer's First Report of Injury or Death | 7/1/2013 | Form 109 Notification of Withdrawal of Claim or Complaint | 7/1/2013 | Form 110 Employee's Claim | 7/1/2013 | Form 112 Appeal to Reviewing Board | 7/1/2013 | Form 113 Agreement to Pay Compensation | 7/1/2013 | Form 115 Third Party Claim / Notice of Lien | 7/1/2013 | Form 116 Request for Lump Sum Conference | 7/1/2013 | Form 116A Agreement to Accept Lump Sum Settlement | 7/1/2013 | Form 116B Addendum to Lump Sum Settlement Agreement | 7/1/2013 | Form 116C Lien Disclosure Form | 7/1/2013 | Form 121 Appeal of Conference Proceeding | 7/1/2013 | Form 126 Employee's Earnings Report | 7/1/2013 | Form 140 Temporary Conference Memorandum Cover Sheet | 7/1/2013 | Form 141 Last Best Offer at Conference | 7/1/2013 | Insurer's Complaint for Modification Discontinuance or Recoupment of Compensation | 7/1/2013 | Insurer's Notification of Acceptance Resumption, Termination or Modification of Weekly Compensation | 7/1/2013 | Insurer's Notification of Denial | 7/1/2013 | Insurer's Notification of Payment | 7/1/2013 | Insurer's Notification of Termination or Modification of Weekly Compensation | 7/1/2013 | To Be Completed By Counsel for the Insurer Prior to Hearing | Michigan Workers' Comp. 2.7.6 b CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | BWC-1-113A Multiple Carrier Redemption Form | 11/1/1997 | BWC-100 Employer's Basic Report of Injury | 10/1/1996 | BWC-104A Application for Mediation or Hearing - Form A | 8/1/1996 | BWC-104B Application for Mediation or Hearing - Form B | 6/1/1998 | BWC-104C Application for Mediation or Hearing - Form C | 10/1/1996 | BWC-106 Supplemental Report of Fatal Injury | 3/1/1998 | BWC-107 Notice of Dispute | 10/1/1996 | BWC-108 Application for Advance Payment | 11/1/1997 | BWC-110 Report on Rehabilitation | 9/1/1996 | BWC-113 Redemption Order | 3/1/1998 | BWC-114 Application for Reimbursement From the Compensation Supplement Fund | 7/1/1996 | BWC-115 Volunatary Payment Form | 11/1/1997 | BWC-117 Employee's Report of Claim | 8/1/1996 | BWC-119 Affidavit In Support of Redemption (Settlement) Agreement | 11/1/1997 | BWC-251 Carrier's Response | 9/1/1998 | BWC-262 Claim for Review | 10/1/1998 | BWC-508 Witness Subpoena / Subpoena for Production of Records | 3/1/1997 | BWC-544 Worker's Settlement Statement | 7/1/1996 | BWC-556 Agreement to Redeem Liability | 11/1/1997 | BWC-701 Notice of Compensation Payments | 10/1/1996 | BWC-728 Amputation Chart | 8/1/1996 | MDL-1-100 Instructions | MDL-480 Instructions for Completing Form MDL-1-104A | 2/1/1991 | Mississippi Workers' Comp. version 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Attachment Sheet | First Report of Injury Instructions | 8/1/2001 | IA-1 First Report of Injury or Illness | 8/1/2001 | MWCC A-16 Notice of Coverage | 6/1/1990 | MWCC B-18 Instructions | 7/1/1996 | MWCC B-18 Notice of First Payment of T.T.D. Benefits | 7/1/1996 | MWCC B-19 Application for Lump Sum Payment | 1/1/2003 | MWCC B-31 Notice of Final Payment | 10/1/2003 | MWCC B-5, 11 Petition to Controvert | 7/1/2001 | MWCC B-5, 22 Answer | 11/1/2001 | MWCC B-52 Employer's Notice of Controversion | 1/1/1993 | MWCC B9, 27 Medical Report | 6/1/1996 | MWCC R-1 Early Notification of Severe Injury | 7/1/1982 | MWCC R-2 Referral For Rehabilitation | 9/1/1981 | Pretrial Statement of Claimant | 12/1/2005 | Pretrial Statement of Claimant Instructions | 12/1/2005 | Missouri Workers' Comp. 2.7.6 b CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | WC-1-EDI Report of Injury | 6/1/2006 | WC-11 Application for Review | 10/1/1992 | WC-1A Notice and Acknowledgement of Right to Workers' Comp. Benefits | 9/1/1994 | WC-2 Receipt and Termination of Comp. | 5/1/2004 | WC-21 Claim for Compensation | 3/1/2004 | WC-22 Answer to Claim for Compensation | 6/1/2004 | WC-3 Notice of Commencement of Comp. Payments | 1/1/1996 | WC-43 Authorization to Inspect/Copy Medical Records | 11/1/1994 | WC-9 Surgeon's Report | 5/4/2004 | WC-G-11 Stipulation for Compromise Settlement | 7/1/2002 | National Labor Relations Board 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$129.00 | Form Names: | Rev: | NLRB-31 Subpoena Duces Tecum | 2/1/1997 | NLRB-32 Subpoena | 2/1/1997 | NLRB-4701 Notice of Appearance | 3/1/1983 | NLRB-4813 Notice of Designation of Representative as Agent for Service of Documents | 11/1/1981 | Return of Service | National UCC version 2.7.6c CLICK HERE TO DOWNLOAD / INSTALL |
$129.00 | Form Names: | Rev: | California UCC Addendum | 6/1/2001 | California UCC Addendum Instructions | 6/1/2001 | UCC-1 Additional Party | 8/22/2011 | UCC-1 Additional Party Instructions | 8/22/2011 | UCC-1 Financing Statement | 4/20/2011 | UCC-1 Financing Statement Addendum | 4/20/2011 | UCC-1 Financing Statement Addendum Instructions | 4/20/2011 | UCC-1 Financing Statement Instructions | 4/20/2011 | UCC-11 Information Request | 5/9/2001 | UCC-11 Information Request Instructions | 5/9/2001 | UCC-3 Additional Party | 8/22/2011 | UCC-3 Additional Party Instructions | 8/22/2011 | UCC-3 Financing Statement Amendment | 5/22/2002 | UCC-3 Financing Statement Amendment Addendum | 4/1/2011 | UCC-3 Financing Statement Amendment Addendum Instructions | 4/1/2011 | UCC-3 Financing Statement Amendment Instructions | 5/22/2002 | UCC-5 Correction Statement | 7/19/2012 | UCC-5 Correction Statement Instructions | 7/19/2012 | Nebraska Workers' Comp. 2.7.7 CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | NWCC Form 1 First Report of Alleged Occupational Injury or Illness | 7/1/1997 | NWCC Form 10T Corporate Executive Officer - Termination of Waiver | 12/1/1996 | NWCC Form 12 Record of Compensation Insurance | 6/1/1995 | NWCC Form 4 Compensation and Expense Report | 1/1/1995 | NWCC Form 4-A Compensation and Expense Report Continuation | 1/1/1991 | NWCC Form 50 Employee's Choice or Change of Doctor Form | 1/1/1997 | NWCC Form 50 Employee's Choice or Change of Doctor Form - Spanish | 1/1/1997 | NWCC Form 63-1 Request for Independent Medical Examiner | 7/1/1997 | NWCC Form 67-2 Notice of Agreement To Use a Named Independent Medical Examiner | 7/1/1997 | Record Search Request | 7/1/1998 | VR-42c Agreement for the Selection of a Vocational Rehabilitation Counselor | 11/1/1999 | VR-42c Agreement for the Selection of a Vocational Rehabilitation Counselor - Spanish | 11/1/1999 | New Hampshire Workers' Comp. 3.7.6 b CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Form 13 WCA Employer's Supplemental Report of Injury | 7/1/1989 | Form 6 WC Notice of Workers' Compensation Insurance Coverage | 7/31/1990 | Form 75 WCA-1 Medical Form | 6/1/1994 | Form 76 WCA Wage Schedule | 1/1/1994 | Form 76 WCA-1 Supplemental Wage Schedule | Form 8 WC Employer's First Report of Occupational Injury or Disease | 7/1/1995 | Form 8a WCA Notice of Accidental Injury or Occupational Disease | 10/1/1995 | Form 9 WCA-2 Application for Reimbursement | 9/1/1994 | Task Analysis | New Jersey Workers' Comp. version 2.7.6 b CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | IA-1 First Report of Injury or Illness | 1/1/2002 | L&I-1 Employer's First Report of Accidental Injury or Occupational Illness | 8/1/1998 | no form name available | 1/1/2002 | SCF-4 Discrimination Complaint | 5/1/2013 | WC CF-11 Record of Informal Hearing | 8/1/1992 | WC CF-66 Application for Informal Hearing | 2/1/2006 | WC DO-100 Order | 8/27/2015 | WC F-367A Respondent's Answer to Claim Petition | 7/1/2004 | WC I-60 Application for Commutation | 6/1/2007 | WC(DO)-100.1 Order (Continuation) | 4/1/1988 | WC(DO)-31 Pre-trial Memorandum | 6/1/2007 | WC(DO)-339 No Insurance Case | 10/1/1997 | WC(DO)-37 Bench Referral | 10/1/1997 | WC(DO)-370 Order Approving Settlement With Dismissal | 4/1/2013 | WC-1 Employer's Report to Division of Workers' Compensation of Accidental Injury or Occupational Disease | 8/1/1998 | WC-101 Notice of Motion for Medical Benefits | 3/1/2007 | WC-102 Answering Statement to Motion for Medical Benefits | 10/1/1994 | WC-171 Respondent's Answer to Dependency Claim Petition | 7/1/2004 | WC-2 Insurer's Initial Notice of Accident and Insurer's and Self-Insurer's Statement of Wages and Agreement to Care for Case | 8/1/1998 | WC-3, 4, 5, 6 Final Report of Accident | 8/1/1998 | WC-365 Employee's Claim Petition | 8/26/2015 | WC-365 Employee's Claim Petition Supplemental Page | 5/7/2015 | WC-366 Dependency Claim Petition | 7/1/2004 | WC-368 Application for Review of Formal Award | 8/26/2015 | WC-369 Answer to Application for Review of Formal Award | 7/1/2004 | WC-3A Report of Death reverse | 8/1/1998 | WC-47 Decision of Dismissal | 7/1/2004 | New Mexico Workers' Comp. 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Instruction Sheet 1 | 12/27/1999 | Instruction Sheet 2 | 12/27/1999 | NOA-1 Notice of Accident | 5/1/1997 | WCA Form E1.2 Employers' First Report of Injury or Illness | 5/1/1993 | WCA Form E6.2 Notice of Benefit Payment | New York Workers' Comp. version 2.7.6 b CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | C-105 Notice of Compliance | 11/1/2001 | C-11 Employer's Report of Injured Employee's Change of Employment Status | 1/1/2011 | C-2 Employer's Report of Work- Related Accident/Occ. Disease instructions | 10/1/2008 | C-22 Application for Approval of Non-Schedule Adjustment | 2/1/2004 | C-220 Notice of Issuance of New Policy or Reinstatment of Policy | 1/1/1997 | C-221 Notice of Cancellation or Intention Not to Renew | 1/1/1997 | C-222 Notice of Issuance of Additions to Existing Policy | 5/1/1987 | C-22b Request to Suspend or Reduce Payment of Compensation | 7/1/1996 | C-240 Employer's Statement of Wage Earning | 1/1/2011 | C-250 Notice of Claim for Reimbursement Out of Special Fund | 3/1/2007 | C-251 Carrier's Request for Reimbursement of Compensation Payments | 11/1/2001 | C-2F Employer's Report of Work- Related Accident/Occ. Disease | 1/1/2014 | C-3 Employee's Claim for Compensation | 1/1/2011 | C-3 Employee's Claim for Compensation instructions | 1/1/2011 | C-3.3 Limited Release of Health Information | 12/1/2009 | C-430S Statement of Rights / Declaracion De Derechos | 3/1/2008 | C-669 Notice to Chair of Carrier's Action on Claim for Benefits | 8/1/2007 | C-669 Notice to Chair of Carrier's Action on Claim for Benefits instructions | 8/1/2003 | C-7 Notice That Right to Compensation is Controverted | 9/1/2008 | C-7 Notice That Right to Compensation is Controverted instructions | 7/1/2007 | C-8.1 Notice of Treatment Issue(s)/Disputed Bill Issue(s) | 12/1/2014 | C-8/8.6 Notice That Payment of Compensation has Been Stopped or Modified | 3/1/2008 | C-8/8.6 Notice That Payment of Compensation has Been Stopped or Modified instructions | 3/1/2008 | C-89.3 Request for Priority Hearing | 1/1/1997 | CB-8 Request for Conciliation | 5/1/1997 | PH-16.2 Statement on Specific Issues in Dispute | 11/1/2008 | R Carrier's Report on Rehabilitation | 8/1/2005 | RB-679 Notice to Chair of Carrier's Action on Appl. for Reopening | 3/1/1997 | RFA-1 Claimant's Request for Further Action | 3/1/2008 | RFA-2 Carrier's/Employer's Request for Further Action | 5/1/2011 | RFA-2 Carrier's/Employer's Request for Further Action instructions | 5/1/2011 | North Carolina Workers' Comp. version 2.7.6 b CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Form 17 Workers' Compensation Notice and Instructions to Employers and Employees | 5/1/2007 | Form 18 Notice of Accident to Employer | 8/6/2008 | Form 18B Claim by Employee or his Personal Representative or Dependents for Workers' Compensation Benefits | 5/1/2002 | Form 18M Employee's Claim for Additional Medical Compensation Pursuant to N.C. Gen. Statute § 97-25.1 | 2/1/2001 | Form 19 Employer's Report of Injury to Employee | 8/6/2008 | Form 21 Agreement for Compensation For Disability Pursuant to NC Gen Stat § 97-82 | 10/1/2006 | Form 22 Statement of Days Worked and Earnings of Injured Employee | 10/1/2006 | Form 24 Application to Suspend Payment of Compensation Pursuant to N.C. Gen. Statute § 97-18.1 | 2/1/2001 | Form 25C Authorization for Rehabilitation Professional To Obtain Medical Records of Current Treatment | 1/1/2004 | Form 25N Notice to the Industrial Commission of Assignment of Rehabilitation Professional Pursuant to Utilization of Rehabilitation Professionals Rule VII | 8/1/2004 | Form 25P Itemized Statement of Charges for Drugs | 2/1/2001 | Form 25R Evaluation for Permanent Impairment | 8/6/2008 | Form 25T Itemized Statement of Charges for Travel | 1/1/2009 | Form 26 Supplemental Agreement as to Payment of Compensation Pursuant to N.C. GEN. STAT. § 97-82 | 8/6/2008 | Form 26A Employer's Admission of Employee's Right to Permanent Partial Disability | 8/6/2008 | Form 26D Agreement for Compensation Under G.S. 97-37 | 2/1/2001 | Form 28 Return to Work Report | 2/1/2001 | Form 28B Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid and Notice of Right to Additional Medical Compensation | 11/1/2003 | Form 28C Report of Employer or Carrier/Administrator of Compensation and Medical Compensation Paid Pursuant to a Compromise Settlement Agreement | 11/1/2003 | Form 28T Notice of Termination of Compensation by Reason of Trial Return to Work | 2/1/2001 | Form 28U Employee's Request that Compensation be Reinstated After Unsuccessful Trial Return to Work | 6/1/2002 | Form 29 Supplementary Report for Fatal Accidents | 2/1/2001 | Form 30A Agreement for Compensation for Death | 11/1/2001 | Form 30D Notice of Death Award | 11/1/2001 | Form 31 Application for Lump Sum Award | 2/1/2001 | Form 33 Request That Claim be Assigned for Hearing | 2/1/2001 | Form 33R Response to Request That Claim Be Assigned for Hearing | 2/1/2001 | Form 36 Subpoena for Witness | 11/1/2005 | Form 42 Application for Appointment of Guardian Ad Litem | 2/1/2001 | Form 44 Application for Review | 4/1/2008 | Form 51 Annual Consolidated Fiscal Report of "Medical Only" or "Lost Time" Cases | 6/1/2005 | Form 60 Employer's Admission of Employee's Right to Compensation Pursuant to N.C. GEN. STAT. § 97-18(b) | 8/6/2008 | Form 61 Denial of Worker's Compensation Claim Pursuant to N.C. GEN. STAT. § 97-18(c) && N.C. GEN. STAT. § 97-18(d) | 10/1/2006 | Form 62 Notice of Reinstatement or Modification of Compensation Pursuant to N.C. GEN. STAT. § 97-32.1 Or N.C. GEN. STAT. § 97118(b) | 10/1/2006 | Form 63 Notice to Employee of Payment of Compensation Without Prejudice to Later Deny the Claim Pursuant to N.C. GEN. STAT. § 97-18(d) | 8/6/2008 | Form 90 Report of Earnings | 2/1/2001 | Ohio Workers' Comp. 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | AC-2 Permanent Authorization | 7/2/1997 | AC-3 Temporary Authorization to Review Information | 7/2/1997 | C-108 Request for Waiver of Appeal | 9/1/1997 | C-110 Agreement to Select the State of Ohio as the State of Exclusive Remedy | 10/23/1997 | C-133 Lost Warrant Affidavit | 11/1/1979 | C-140 Application for Wage Loss Compensation | 8/14/1997 | C-140 Pg. 2 Medical Report | C-141 Wage Loss Statement For Job Search | 8/12/1997 | C-167-T Objection to Tentative Order Awarding Permanent Partial Disability Compensation | 12/5/1997 | C-17 Pharmacy Invoice | 2/1/1992 | C-181 Fee Bill Inquiry | 12/1/1990 | C-19 Service Invoice | 7/23/1997 | C-23 Change of Physician Notice | 8/22/1997 | C-230 Authorization to Receive Workers' Compensation Check | 8/14/1997 | C-240 Settlement Agreement and Application for Approval of Settlement Agreement | 3/23/1998 | C-241 Amended Settlement Agreement and Release | 3/23/1998 | C-44 Physician's Certificate in Proof of Death | 12/1/1992 | C-5 Additional Information for Death Benefits | 9/9/1996 | C-58 Application for Adjustment of Claim in Case of Fatal Injury | 10/1/1991 | C-59 Self-Insurers' Agreement as to Compensation on Account of Death | 2/1/1986 | C-60 Travel Expense Statement | 6/19/1997 | C-77 Injured Worker's Change of Address Notification | 11/12/1997 | C-84 Request for Temporary Total Compensation | 9/24/1997 | C-84 Instructions | C-86 Motion | 10/21/1998 | C-9 Physician's Report/Treatment Plan for Industrial Injury or Occupational Disease | 4/21/1998 | C-92 Application for the Determination of the Percentage of Permanent Partial Disability | 10/30/1997 | C-92-A Application for Increase in Percentage of Permanent Partial Disability | 9/24/1997 | C-94-A Wage Statement | 9/2/1997 | FROI-1 First Report of an Injury, Occupational Disease or Death | 2/1/1998 | IC-MED-5 Affidavit | 1/1/1985 | MEDCO-8 Pg 2 Self-Insured Employer/Injured Worker Screening | 8/30/1995 | MEDCO-8 Pg. 1 Self-Insured Employer/Injured Worker Screening | 8/30/1995 | O-D-4A Attending Physician's Report of Occupational Disease | OD-58-22 Application for Adjustment of Claim in Case of Death Due to Occupational Disease | 7/1/1993 | OIC 1004 Request for Continuance | 2/1/1998 | OIC 3000 Notice of Appeal | 7/1/1998 | OIC 3003 Application for Lump Sum Payment | 5/1/1984 | OIC 3012 Application for Compensation for Permanent Total Disability | 8/1/1998 | OIC 3017 Application for Payment of Compensation Accrued at Time of Death | 5/1/1984 | OIC 3018 Application for Additional Award for Violation of Specific Requirements in a Workers' Comp. Claim | 7/1/1988 | OIC 3019 Application for Additional Awards for Violation of Specific Requirement | 3/1/1989 | OIC 3022 Certificate for Lump Sum Payment of Attorney Fees | 11/1/1990 | OIC 3050 Request for .522/.52 Relief | 1/1/1998 | OIC-1084 Settlement of Alleged Violation of a Specific Safety Requirement | 7/1/1991 | OIC-2013 Agreement as to Compensation for Permanent Disability | 1/6/1994 | OIC-2020 Pg. 1 Report of Special Eye Examination | 12/1/1986 | OIC-2020 Pg. 2 Report of Special Eye Examination | 12/1/1986 | OIC-3002 IC-90 Employee's Notice of Election to Receive Compensation for Partial Disability | 5/1/1984 | OIC-3004 IC-88 Application for Reconsideration | 9/1/1995 | R-1 Authorization of Representative of Employer | 12/1/1988 | R-2 Authorization of Representative of Claimant | 3/10/1998 | R-3 Request to Inspect Claim File or to Obtain Screens | 12/1/1988 | SI-28 Filing of Complaint Against a Self-Insured Employer | 4/30/1996 | SI-42 Self Insured Joint Settlement Agreement and Release | 12/1/1997 | SI-43 Acknowledgement of the Self Insured Joint Settlement Agreement and Release | 10/1/1997 | U-136 Request for Election of Coverage for Ministers or Associate Ministers | 12/2/1996 | U-3 Application for Coverage | 6/26/1997 | U-3-B Application for Household Domestic Employees Only | 11/17/1995 | U-9 Application for Transfer of Workers' Compensation Account and Premium Obligation to Succeeding Employer | 1/1/1988 | Oklahoma Workers' Comp. version 2.7.7 CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Form 10 Answer and Pretrial Stipulation Offered By Respondent | 1/1/2007 | Form 10-M Response To Request For Payment of Charges For Medical or Rehabilitation Services | 2/1/2006 | Form 100 Claimant's Application and Order For Dismissal | 2/1/2006 | Form 11 Motion To Terminate Temporary Compensation | 12/1/1999 | Form 13 Request For Prehearing Conference | 2/1/2006 | Form 14 Agreement Between Employer and Employee As To Fact With Relation To An Injury and Payment of Compensation | 2/1/2006 | Form 17 Disclosure Statement | 2/1/2006 | Form 18 Request For Administrative Review of Disputed Medical Charges | 2/1/2006 | Form 19 Request For Payment of Charges For Medical or Rehabilitation Services | 2/1/2006 | Form 1A Notice and Instruction to Employers and Employees | 7/1/2005 | Form 1A Notice and Instruction to Employers and Employees (Spanish) | 7/1/2005 | Form 2 Employer's First Notice of Injury | 2/1/2006 | Form 20 Proof of Loss For Spouse and Children | 2/1/2006 | Form 3 Employee's First Notice of Accidental Injury and Claim For Compensation | 2/1/2006 | Form 3-A Claimant's First Notice of Death Claim for Compensation | 2/1/2006 | Form 3-B Employee's First Notice of Occupational Disease and Claim for Compensation | 2/1/2006 | Form 3-F Employee's Claim for Benefits From the Multiple Injury Trust Fund | 2/1/2006 | Form 4 Attending Physician's Report and Notice of Treatment | 2/1/2006 | Form 4A Attending Physician's Progress Report | 2/1/2006 | Form 5 Physician's Release and Restrictions | 2/1/2006 | Form 6 Employer's, Insurance Carrier's, Or Claims Servicing Company's Initial Report of Payment of Compensation | 6/1/1995 | Form 7 Designation of Service Agent | 2/1/2006 | Form 8 Acknowledgement By Employee of Receipt of Compensation Payment | 12/1/1999 | Form 9 Motion To Set For Trial | 2/1/2006 | Pennsylvania Workers' Comp. version 2.7.7 CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | LIBC Addendum | LIBC-10 Authorization for Alternative Delivery of Compensation Payments | 9/1/2013 | LIBC-25 Appeal From Judge's Findings of Fact and Conclusions of Law | 6/1/2004 | LIBC-336 Agreement For Compensation For Disability Or Permanent Injury | 9/1/2013 | LIBC-337 Supplemental Agreement For Compensation For Disability Or Permanent Injury | 9/1/2013 | LIBC-338 Agreement For Compensation For Death | 9/1/2013 | LIBC-339 Supplemental Agreement For Compensation For Death | 9/1/2013 | LIBC-34 Petition For Commutation of Compensation Under the Pennsylvania Workers' Compensation Act of 1915 | 11/1/1997 | LIBC-340 Agreement To Stop Weekly Workers' Compensation Payments (Final Receipt) | 9/1/2013 | LIBC-344 Employer's Report of Occupational Injury or Disease | 1/1/2001 | LIBC-35 Answer To Petition For Commutation | 12/1/1997 | LIBC-362 Claim Petition For Workers' Compensation | 9/1/2013 | LIBC-363 Fatal Claim Petition For Compensation By Dependents of Deceased Employees | 9/1/2013 | LIBC-364B Defendant's Answer To Claim Petition Under Pennsylvania Occupational Disease Act | 9/1/2013 | LIBC-374 Defendant's Answer To Claim Petition Under Pennsylvania Workers' Compensation Act | 9/1/2013 | LIBC-376 Petition For Joinder of Additional Defendant | 9/1/2013 | LIBC-377 Answer To Petition | 9/1/2013 | LIBC-378 Petition | 9/1/2013 | LIBC-380 Third Party Settlement Agreement | 9/1/2013 | LIBC-384 Fatal Claim Petition For Compensation By Dependents For Death Covered By the Pennsylvania Occupational Disease Act | 9/1/2013 | LIBC-386 Fatal Claim Petition For Compensation By Dependents For Death Resulting From Occupational Disease | 9/1/2013 | LIBC-392 Statement of Account of Compensation Paid | 11/1/1997 | LIBC-392A Final Statement of Account of Compensation Paid | 9/1/2008 | LIBC-396 Occupational Disease Claim Petition | 9/1/2013 | LIBC-480 Subpoena | 8/1/2010 | LIBC-494A Statement of Wages | 9/1/2013 | LIBC-494C Statement of Wages | 9/1/2013 | LIBC-495 Notice of Compensation Payable | 9/1/2013 | LIBC-496 Notice of Workers' Compensation Denial | 9/1/2013 | LIBC-497 Physician's Affidavit of Recovery | 9/1/2013 | LIBC-498 Commutation of Compensation | 12/1/1997 | LIBC-499 Petition For Physical Examination Or Expert Interview of Employee | 9/1/2013 | LIBC-501 Notice of Temporary Compensation Payable | 9/1/2013 | LIBC-502 Notice Stopping Temporary Compensation | 9/1/2013 | LIBC-601 Utilization Review Request | 11/1/2013 | LIBC-603 Petition For Review of Utilization Review Determination | 9/1/2013 | LIBC-606 Request for Hearing to Contest Fee Review Determination | 9/1/2013 | LIBC-662 Application For Supersedeas Fund Reimbursement | 7/1/2007 | LIBC-686 Petition For Penalties | 6/1/2004 | LIBC-749 Death Claim Supplement to Compromise and Release Agreement | 2/1/2011 | LIBC-750 Employee Report of Wages and Physical Condition | 9/1/2013 | LIBC-751 Notification of Suspension or Modification | 9/1/2013 | LIBC-753 Notice of Request for an Informal Conference | 9/1/2013 | LIBC-754 Informal Conference Agreement Form | 9/1/2013 | LIBC-755 Compromise and Release Agreement By Stipulation Pursuant To Section 449 of the Workers' Compensation Act | 4/1/2018 | LIBC-756 Employee's Report of Benefits for Offsets | 9/1/2013 | LIBC-757 Notice of Ability To Return To Work | 9/1/2013 | LIBC-760 Employee Verification of Employment, Self-Employment or Change in Physical Condition | 9/1/2013 | LIBC-761 Notice of Workers' Compensation Benefit Offset | 8/1/2001 | LIBC-762 Notice of Suspension For Failure To Return | 12/1/1997 | LIBC-763 Notice of Reinstatement of Workers' Compensation Benefits | 12/1/1997 | LIBC-764 Notice of Change of Workers' Compensation Disability Status | 9/1/2013 | LIBC-765 Impairment Rating Evaluation Appointment | 9/1/2013 | LIBC-766 Request For Designation of a Physician To Perform an Impairment Rating Evaluation | 9/1/2013 | LIBC-767 Impairment Rating Determination Face Sheet | 9/1/2013 | LIBC-90 Electronic Data Interchange First Report of Injury | 9/1/2013 | LIBC-91 Electronic Data Interchange Subsequent Report of Injury | 9/1/2013 | Start New Case Form | 12/6/2001 | South Carolina Workers' Comp. version 2.7.6 b CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Form 12-A First Report of Injury or Illness | 4/1/2006 | Form 15 Temporary Compensation Report | 10/1/2004 | Form 15S Supplemental Report of Varying Temporary Partial Payments | 3/1/1997 | Form 16 Agreement for Permanent Disability/Disfigurement Compensation | 3/1/1997 | Form 17 Receipt of Compensation | 3/1/1997 | Form 18 Periodic Report | 3/1/1996 | Form 19 Status Report and Compensation Receipt | 3/1/1996 | Form 20 Statement of Earnings of Injured Employee | 3/1/1997 | Form 21 Employer's Request for Hearing | 3/1/1997 | Form 30 Request for Commission Review | 3/1/1997 | Tennessee Workers' Comp. version 2.7.7 CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | C-22 Notice of First Payment of Compensation | 12/1/2007 | C-23 Notice of Denial of Claim for Compensation | 11/1/2015 | C-27 Notice of Change or Termination of Compensation Benefits | 12/1/2007 | C-27 Notice of Controversy | 12/1/2007 | C-29 Final Report of Payment and Receipt of Compensation | 12/1/2007 | C-30 Attending Physician's Report | 3/1/2015 | C-30A Final Medical Report | 7/1/2014 | SD1 Workers' Compensation Statistical Data Form | 6/1/2007 | Texas Workers' Comp. version 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Affidavit - Defendant's Atty | Affidavit - Plaintiff's | Affidavit - Plaintiff's Atty's | DWC-1 Employer's First Report of Injury or Illness | 10/1/2005 | DWC-1 Filing Instructions | DWC-1 Instructions | DWC-153 Request for Copies of Confidential Claimant Information | 10/1/2006 | DWC-153 Instructions | 10/1/2006 | DWC-155 Request for Record Check | 10/1/2005 | DWC-155 Instructions | DWC-156 Prospective Employment Authorization and Certification | 10/1/2005 | DWC-156 Filing Instructions | DWC-2 Employer's Report for Reimbursement of Voluntary Payment | 10/1/2005 | DWC-2 Filing Instructions | DWC-20 Correction/Revision/Endorsement to Existing Policy | 10/1/2005 | DWC-20 INS Insurance Carrier Notice Coverage/Cancellation/Non-renewal of Coverage | 10/1/2005 | DWC-21 Payment of Compensation or Notice of Refused/Disputed Claim | 10/1/2005 | DWC-21 Filing Instructions | DWC-22 Required Medical Examination Notice or Request for Order | 7/1/2011 | DWC-22 Filing Instructions | DWC-24 Benefit Dispute Agreement | 10/1/2005 | DWC-24 Filing Instructions | DWC-25 Benefit Dispute Settlement | 10/1/2005 | DWC-25 Filing Instructions | DWC-26 Request for Reimbursement of Payment Made By Health Care Provider | 5/1/2011 | DWC-3 Employer's Wage Statement | 10/1/2005 | DWC-31 Application for Commission Approval of Change in the Payment Period and/or Purchase of an Annuity | 10/1/2005 | DWC-32 Notice of Maximum Medical Improvement/Impairment Rating Dispute | 5/1/2008 | DWC-33 Carrier's Request for Reduction of Income Benefits Due to Contribution | 10/1/2005 | DWC-33 Filing Instructions | DWC-34 Notice of Intent to Suspend Temporary Income Benefits | 10/1/2005 | DWC-34 Filing Instructions | DWC-4 Employer's Contest of Compensability | 10/1/2005 | DWC-4 Filing Instructions | DWC-41 Employee's Notice of Injury or Occupational Disease and Claim for Compensation | 3/1/2007 | DWC-41 Filing Instructions | 3/1/2007 | DWC-44 Election to Engage in Arbitration | 6/1/2012 | DWC-44 Filing Instructions | DWC-45 Request for a Benefit Review Conference | 11/1/2011 | DWC-45 Filing Instructions | DWC-45a Request for a Medical Review Hearing | 9/1/2007 | DWC-45a Request for a Medical Review Hearing (Spanish) | 10/1/2007 | DWC-45m Request to Schedule, Reschedule, or Cancel a Benefit Conference to Appeal a Medical Fee Dispute Decision | 6/1/2012 | DWC-46 Employee's Request for Impairment Income Benefits | 10/1/2005 | DWC-47 Request for Payment of Advance Compensation | 10/1/2005 | DWC-48 Filing Instructions | 6/1/2006 | DWC-49 Request to Schedule a Medical Contested Case Hearing (MCCH) | 6/1/2012 | DWC-5 Employer Notice of Termination of Coverage | 10/1/2005 | DWC-5 Instructions | DWC-51 Election For Lump Sum Impairment Income Benefits | 10/1/2005 | DWC-51 Instructions | DWC-52 Application for Supplemental Income Benefits | 4/1/2009 | DWC-53 Employee's Request to Change Treating Doctors | 2/1/2008 | DWC-53 Filing Instructions | DWC-6 Supplemental Report of Injury | 10/1/2005 | DWC-6 Instructions | 10/1/2005 | DWC-60 Request for Medical Dispute Resolution | 6/1/2012 | DWC-60 Instructions | DWC-62 Notice of Medical Payment Dispute | 7/1/2007 | DWC-62 Instructions | DWC-69 Report of Medical Evaluation | 10/1/2005 | DWC-69 Report of Medical Evaluation Instructions | DWC-7 Non-Covered Employer's Report of Occupational Injury or Illness | 10/1/2005 | DWC-7 Instructions | DWC-73 Texas Workers' Compensation Work Status Report | 10/1/2005 | DWC-73 Texas Workers' Compensation Work Status Report Instructions | DWC-83 Agreement to Affirm Independent Relationship / Employer-Employee Relationship for Certain Building and Construction Workers | 10/1/2005 | Longshore Claims Records | Medical Records | Plain Language Notice of Denial of Compensability/Liability and Refusal to Pay Benefits | 10/1/2005 | Plain Language Notification of Change of Amount of Indemnity Benefit Payment | 10/1/2005 | Plain Language Notification of Change of Indemnity Benefit Payment Type | 10/1/2005 | Plain Language Notification of Disputed Issue(s) and Refusal to Pay Benefits | 10/1/2005 | Plain Language Notification of Employer Full Salary Payment | 10/1/2005 | Plain Language Notification of First Death Benefit Payment | 10/1/2005 | Plain Language Notification of First Lifetime Income Benefit Payment | 10/1/2005 | Plain Language Notification of First Temporary Income Benefit Payment | 10/1/2005 | Plain Language Notification of Maximum Medical Improvement | 10/1/2005 | Plain Language Notification of Reinstatement of Indemnity Benefit Payment | 10/1/2005 | Plain Language Notification of Suspension of Indemnity Benefit Payment | 10/1/2005 | Prior Employment Records | Request for Travel Reimbursement | 6/1/2006 | Social Security Disability Records | Verification - Attorneys | Veterans Administration Records | US Bankruptcy version 2.7.61 b CLICK HERE TO DOWNLOAD / INSTALL |
$129.00 | Form Names: | Rev: | 2400A Reaffirmation Agreement | 12/1/2015 | 2400A Reaffirmation Agreement Instructions | 12/1/2015 | 2540 Subpoena for Rule 2004 Examination | 12/1/2015 | 2550 Subpoena in an Adversary Proceeding | 12/1/2015 | 2560 Subpoena in a Case Under the Bankruptcy Code | 12/1/2015 | 410 Proof of Claim | 4/2/2016 | 410 Proof of Claim Instructions | 12/1/2015 | B1040 Adversary Proceeding Cover Sheet | 12/1/2015 | B2500B Summons and Notice of Pretrial Conference in an Adversary Proceeding | 12/1/2015 | B2500C Summons and Notice of Trial in an Adversary Proceeding | 12/1/2015 | B2500D Third-Party Summons | 12/1/2015 | California Form 110 Notice of Entry of Judgement or Order and Certificate of Mailing | 1/1/1989 | US BPD State and Local Government Series version 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$129.00 | Form Names: | Rev: | PD F 4144 TDS Subscription | 8/1/2005 | PD F 4144 TDS Subscription Instructions | 8/1/2005 | PD F 4144-1 TDS Account Information | 8/1/2005 | PD F 4144-1 TDS Account Information Instructions | 8/1/2005 | PD F 4144-2 TDS Schedule of Cert of Indebtedness | 8/1/2005 | PD F 4144-2 TDS Schedule of Cert of Indebtedness Instructions | 8/1/2005 | PD F 4144-3 TDS Schedule of US Treasury Notes | 8/1/1997 | PD F 4144-4 TDS Schedule of US Treasury Bonds | 8/1/1997 | PD F 5237 Subscription for Purchase of U.S. Treasury Securities | 8/1/2005 | PD F 5237 Subscription for Purchase of U.S. Treasury Securities Instructions | 8/1/2005 | PD F 5238 Request for Redemption of U.S. Treasury Securities | 8/1/2005 | PD F 5238 Request for Redemption of U.S. Treasury Securities Instructions | 8/1/2005 | PD F 5291 Special Zero Subscription | 1/1/1995 | PD F 5291-1 Special Zero Account Information | 1/1/1995 | PD F 5291-2 SZ Schedule Certificates of Indebtedness | 12/1/1994 | PD F 5291-3 SZ Schedule of Treasury Notes | 12/1/1994 | US District Court version 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$129.00 | Form Names: | Rev: | Answering Statement | 11/1/1999 | AO 133 Bill of Costs | 12/1/2009 | AO 240 Application to Proceed | 6/1/2009 | AO 451 Certification of Judgment | 1/1/2009 | AO 458 Appearance | 1/1/2009 | AO-187 Exhibit List | 7/1/1987 | AO-398 Notice of Suit and Service Waiver Request | 1/1/2009 | AO-399 Waiver of Service of Summons | 1/1/2009 | AO-440 Civil Summons | 6/1/2012 | AO-441 Third Party Summons | 12/1/2009 | AO-88 Civil Subpoena | 2/1/2014 | AO-88 Civil Subpoena Instructions | 2/1/2014 | AO-88a Subpoena to Testify at a Deposition in a Civil Action | 2/1/2014 | AO-88a Subpoena to Testify at a Deposition in a Civil Action Instructions | 2/1/2014 | AO-88b Civil Subpoena Instructions | 2/1/2014 | AO-88b Subpoena to Produce Documents, Information, or Objects or to Permit Inspection of Premises in a Civil Action | 6/1/2009 | AO-89 Subpoena in a Criminal Case | 8/1/2009 | AO-90 Criminal Deposition Subpoena | 8/1/2009 | CA Notice of Appeal | Demand for Arbitration | 4/1/2004 | GA Application for Admission Pro Hac Vice | GA Application for Admission to the Bar | JS-44 Civil Cover Sheet | 12/1/2012 | JS-44 Civil Cover Sheet - GA | 12/1/2000 | JS-44/D.C. | JS-44C/EDNY | 1/1/2013 | JS-44C/SDNY | 7/1/2016 | JS-44C/SDNY Instructions | 12/1/1996 | Magistrate Request | 2/1/1994 | MO Civil Track Information Statement | MO Order | MO Original Filing Form | OH Certificate of Judgment Lien upon Lands and Tenements | 1/1/1996 | OH Civil Case Information Statement | 1/1/1992 | OH Civil Case Information Statement instructions | 5/1/1993 | OH Cover Sheet | 7/1/1985 | OH Exhibit Receipt | 1/1/1996 | OH Praecipe | 4/1/1993 | OH Stipulation for Dismissal, Leave to Plead, etc. | 1/1/1996 | PA Signature Document | Request for Subpoenas | Request for Summons | SDNY Rule 7.1 Statement | Southern District of New York Related Case Statement | 5/1/2014 | WML Financial and Civil Allotment Sheet | 6/1/2004 | US Longshore Harbor Workers' Comp. version 2.7.7 CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Administrative Subpoena to Appear and Testify at a Deposition | 11/1/2010 | Administrative Subpoena to Appear and Testify at a Hearing | 11/1/2010 | Administrative Subpoena to Produce Documents, Information or Objects or to Permit Inspection of Premises | 11/1/2010 | Form 180 - Request Pertaining To Military Records | 10/1/2010 | Form 180 Instructions | 10/1/2010 | IRS 4506 Request for Copy of Tax Form | 9/1/2013 | Longshore Claims Records | LS-1 Request for Examination and/or Treatment | 10/1/2010 | LS-18 Pre-Hearing Statement | 9/1/2010 | LS-200 Report of Earnings | 4/1/2009 | LS-201 Notice of Employee's Injury or Death | 1/1/1999 | LS-202 Employer's First Report of Injury or Occupational Illness | 4/1/2012 | LS-203 Employee's Claim for Compensation | 3/1/2012 | LS-204 Attending Physician's Supplementary Report | 4/1/2012 | LS-206 Payment of Compensation Without Award | 1/1/2015 | LS-207 Notice of Controversion of Right to Compensation | 5/1/2015 | LS-208 Notice of Final Payment or Suspension of Compensation Payments | 1/1/2018 | LS-210 Employer's Supplementary Report of Accident or Occupational Illness | 7/1/2010 | LS-222 Carrier's or Self Insurer's Report on Rehabilitation to District Director | 6/1/1997 | LS-226a Subpoena Duces Tecum | 3/1/1985 | LS-262 Claim for Death Benefits | 4/1/2012 | LS-265 Certification of Funeral Expenses | 9/1/2010 | LS-266 Application For Continuation of Death Benefit For Student | 7/1/2010 | LS-33 Approval of Compromise of Third Person Cause of Action | 1/1/2003 | Medical Records | OSHA 301 Injury and Illness Incident Report | 1/1/2004 | OWCP-5a Psychiatric/Psychological Work Capacity Evaluation | 10/1/2001 | OWCP-5b Cardiovascular/Pulmonary Work Capacity Evaluation | 10/1/2001 | OWCP-5c Musculoskeletal Work Capacity Evaluation | 10/1/2001 | Prior Employment Records | Social Security Disability Records | SSA-3288 Consent for Release of Information | 7/1/2010 | SSA-7050-F3 Request for SSA Earnings Info | 1/1/2014 | VA Form 10-5345 Request For and Authorization to Release Medical Records or Health Information | 5/1/2005 | Veterans Administration Records | Utah Workers' Comp. 2.7.6 b CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Form 025 Claim for Dependents' Benefits and/or Burial Benefits | 7/1/2001 | Form 046 Authorization to Release Medical Records | 6/1/2003 | Form 089 Employee Notification of Denial of Claim | 10/1/2000 | Form 110 Release to Return to Work | 3/1/2000 | Form 122 Employer's First Report of Injury or Illness | 1/1/2002 | Form 122 Employer's First Report of Injury or Illness | 1/1/2002 | Form 130 Insurance Company's and Self-Insurer's Final Report of Injury and Statement of Losses | 11/1/2001 | Form 134 Application for Lump Sum or Advance Payment | 2/1/2002 | Form 141 Initial Statement of Insurance Carrier or Self-Insurer with Respect to Payment of Benefits | 8/1/2002 | Form 142 Statement of Insurance Carrier or Self-Insurer with Respect to Discontinuance of Benefits | 8/1/2002 | Form 206 Injured Worker Status Report | 3/1/2000 | Form 219 Permanent Partial Disability Agreement | 8/26/2003 | Form 221 Restorative Services Authorized/Denial | Form 221 Restorative Services Authorized/Denial | 4/22/2003 | Form 441 Insurance Carriers/Self-Insurer's Notice of Further Investigation of a Workers' Compensation Claim | 11/1/1999 | Vermont Workers' Comp. 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | Form 1 Employee's Claim and Employer First Report of Injury | 4/1/1998 | Form 10/10s Certificate of Dependency and Employee Exemption Report | 6/1/1997 | Form 13 Report of Benefits and Related Expenses Paid | 4/1/1998 | Form 14 Settlement Agreement (medical benefits open) | 4/1/1998 | Form 15 Settlement Agreement | 4/1/1998 | Form 21 Agreement for Temporary Total Disability Compensation | 12/1/1997 | Form 22 Agreement for Permanent Partial Disability Compensation | 6/1/1997 | Form 23 Agreement for Compensation in Fatal Cases | 4/1/1998 | Form 24 Agreement for Temporary Partial Disability Compensation | 6/1/1997 | Form 25 Wage Statement (Report of Employee's Wages) | 6/1/1997 | Form 25s Weekly Net Income Worksheet | 5/1/1997 | Form 27 Notice of Intention to Discontinue Payments | 8/1/1997 | Form 28 Notice of Change in Compensation Rate For Injuries After July 1, 1986 | 6/1/1998 | Form 29 Application for Exclusion From the Provisions of the Vermont Workers' Compensation Act | 4/1/1998 | Form 4 Report of Fatal Accident | 4/1/1998 | Form 5 Employee's Notice of Injury and Claim for Compensation | 4/1/1998 | Form 6 Notice and Application for Hearing | 6/1/1997 | Form 7 Medical Authorization | 6/1/1997 | Form 8 Notice of Intent to Change Health Care Provider | 6/1/1997 | Virginia Workers' Comp. 2.7.7 CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | VWC 3A Supplementary Report | 9/1/1999 | VWC Form 3 Employer's First Report of Accident | 3/22/2002 | VWC Form 3 Instructions | 3/22/2002 | VWC Form 4 Memorandum of Agreement | 9/1/1999 | VWC Form 4 Instructions | 9/1/1999 | VWC Form 45A Report of Minor Injuries | 10/1/1991 | VWC Form 45A Instructions | 9/1/1999 | VWC Form 45G Report of Medical Costs | 9/1/1999 | VWC Form 45G Instructions | 9/1/1999 | VWC Form 46 Agreed Statement of Fact | 9/1/1999 | VWC Form 46 Instructions | 9/1/1999 | VWC Form 4A Supplemental Memorandum of Agreement | 9/1/1999 | VWC Form 4A Instructions | 9/1/1999 | VWC Form 5 Claim for Benefits | 9/1/2000 | VWC Form 5 Instructions | 9/1/2000 | VWC Form 5A Employer's Application for Hearing | 9/1/1999 | VWC Form 5A Instructions | 9/1/1999 | VWC Form 6 Attending Physician's Report | 10/1/1991 | VWC Form 6 Instructions | 10/1/1991 | VWC Form 7A Wage Chart | 9/1/1999 | Wisconsin Workers' Comp. 2.7.6 c CLICK HERE TO DOWNLOAD / INSTALL |
$179.00 | Form Names: | Rev: | WKC-12 Employer's First Report of Injury or Disease (rev. 2/98) | 2/1/1998 | WKC-13 Supplementary Report on Accidents and Industrial Diseases (rev. 11/97) | 11/1/1997 | WKC-13-A Wage Information Supplement | 4/1/1998 | WKC-135 Death Benefit Stipulation | 9/1/1994 | WKC-136 Advancement or Lump Sum Request | 7/1/1996 | WKC-16 Medical Report on Industrial Injury (rev. 4/98) | 4/1/1998 | WKC-16-B Petitioner's Report on Accident or Industrial Disease in Lieu of Testimony (rev. 12/97) | 12/1/1997 | WKC-17 Subpoena | 11/1/1998 | WKC-170 Third Party Proceeds Distribution Agreement (rev. 11/96) | 11/1/1996 | WKC-176 Compromise Agreement (rev. 7/96) | 7/1/1996 | WKC-177 Stipulation | 9/1/1994 | WKC-19 Admission to Service and Answer to Application (rev. 8/96) | 8/1/1996 | WKC-28 Petition for Review of Findings and Order of Administrative Law Judge (rev. 7/96) | 7/1/1996 | WKC-35 WC Hearing Appearance Permit Application | 9/1/1997 | WKC-6743 Vocational Expert Report (rev. 7/96) | 7/1/1996 | WKC-7 Hearing Application (rev. 11/96) | 11/1/1996 | WKC-7359 Temporary Partial Disability | 5/1/1997 | WKC-9380 1992 Necessity of Treatment Dispute Resolution Request | 4/1/1996 | WKC-9488 Voluntary and Informed Consent for Disclosure of Health Care Information | 9/1/1998 |