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.
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Legal Forms - Mandatory
Please the select the form and click on the link to download.
Mandatory Forms (A-R)
Application to Workers' Compensation Judge (Revised 10/1/15)
Combined Petition for Lump Sum Payment (Effective 4/1/16)
Health Care Provider (HCP) Disagreement Form
Notice of Acceptance or Rejection of Recommended Resolution
Notice of Disqualification
Notice of Hearing
Request for Setting
Response
Mandatory Forms (S-Z)
Summons for Application to Director (Effective 10/1/15)
Summons for Application to Workers' Compensation Judge (Revised 10/1/15)
Summons for Petition for Lump Sum Payment (Effective 10/1/15)
Summons for Workers' Compensation Complaint
Worker's Authorization for Use and Disclosure of Health Records (Revised 7/26/16)
Worker's Compensation Complaint (Revised 10/1/15)
Legal Forms - Optional
Please the select the form and click on the link to download.
Optional Forms (A-R)
Health Care Provider Selection Letter - Employer/Insurer Choice
Health Care Provider Selection Letter - Worker Choice
Joint Request for Expedited Section 52-5-12 Hearing
Joint Waiver of Disqualification
Joint Waiver of Service of Process
Joint Waiver of Disqualification and Waiver of Service of Process
Optional Forms (S-Z)
Objection to Notice of Change of Health Care Provider
Out of State Health Care Provider Affidavit and Order Granting Approval (Revised 10/1/15)
Legal Forms - Packets
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Packets
Application to Workers' Compensation Judge Packet
Combined Lump Sum Payment Packet
Out of State Health Care Provider Packet
Workers' Compensation Complaint Form Packet
Uninsured Employers Packet
Miscellaneous Forms
Average Weekly Wage
Notice of Accident
Report Fraud
Insurance Forms
Please the select the form and click on the link to download.
Coverage
Executive Employee Affirmative Election
Revocation of Prior Election
Self-Insurance
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
Proof of Coverage Profile: E8
Inpatient Data Supplement: E10-1
Medical Forms
Medical Service Referral
Motion for Out of State HCP
Release for Health Care Records (HIPAA)