Instructions for downloading:

1. The sections are separated by categories and forms that pertain to that section are listed in the boxes.
2. When you locate the form you need, click on the icon for the specific format to download the form.
3. The formats are  for Microsoft Word,  for Microsoft Excel, or  for Adobe PDF.

If you need to install the Adobe Acrobat Reader Program , click here to be taken to the Adobe site to download the program (it is free to download).

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*Note: To Use Fillable Forms

When opening fillable forms, right click and choose Save Target As. Save the form on your computer. Fill out the form, save, and submit to Clerk of the Court.

Legal Forms - Mandatory

Please the select the form and click on the link to download.

Mandatory Forms (A-R)

Application to Director    
Application to Workers' Compensation Judge     
Complaint with Two Employers/Insurers     
Health Care Provider (HCP) Disagreement Form   
Informal Response  
Joint Request for Expedited Section 52-5-12 Hearing   
Notice of Acceptance or Rejection of Recommended Resolution      
Petition for Lump Sum Payment   

Mandatory Forms (S-Z)

Request for Setting   
Subpoena  
Summons for Application to Director    
Summons for Application to Workers' Compensation Judge   
Summons for Petition for Lump Sum Payment   
Summons for Workers' Compensation Complaint   
Uninsured Employers' Fund (UEF) Complaint   
Worker's Authorization for Use and Disclosure of Health Records (HIPAA)    
Worker's Compensation Complaint   

Legal Forms - Optional

Please the select the form and click on the link to download.

Optional Forms (A-R)

Additional Page if Needed   
Change of Address   
Form Letter to Health Care Provider   
Joint Waiver of Disqualification     

Optional Forms (S-Z)

Notice of Change of Health Care Provider      
Notice of Disqualification     
Out of State Health Care Provider Affidavit/Order Granting Approval   
Worker's Response   

Legal Forms - Packets

Notice: Forms found in packets are put together so that filers know what forms are needed. Despite forms being together in a packet, when e-filing, forms must be filed individually.

Please the select the form and click on the link to download.

Packets

Application to Director Packet 
Application to Workers' Compensation Judge Packet 
Lump Sum Payment Packet 
Out of State Health Care Provider Packet 
Workers' Compensation Complaint Form Packet 
Uninsured Employers Packet  

Miscellaneous Forms

Affidavit of Annual Safety Inspection    
Notice of Accident  
Notice of Accident in two parts (download both pieces)  
Report Fraud  

Insurance Forms

Please the select the form and click on the link to download.

Coverage

Election to be Subject  
Revocation of Prior Election  

 

 

Self-Insurance

Amendatory Endorsement 
Application - Individual   
Application - Group   
Board of Directors Resolution    
Letter of Credit - Individual   
Letter of Credit - Group 
Surety Bond - Individual 
Surety Bond - Group 
Parental Guaranty for Subsidiaries   

Data Reporting

Please the select the form and click on the link to download.

Reporting Forms

EDI Trading Partner Profile: E7  
Inpatient Medical Data: E9  
Proof of Coverage Sender/Vendor Information: P7  
Proof of Coverage Insurer Information: P8    

Medical Forms

Approval of Out of State HCP Letter  
Independent Medical Examiner Application  
Medical Service Referral     
Provider's Report of Physical Ability (PROPA)   
Release for Health Care Records (HIPAA)