Workers' Compensation Forms

Employee claim form for workers' compensation benefits in California. Employer must provide within one working day of learning of a workplace injury or illness.

Settlement agreement closing the workers' compensation claim, typically for a lump sum. Must be approved by a workers' comp judge or board in most states.

Employer's First Report of Injury or Occupational Illness under the Longshore and Harbor Workers' Compensation Act. Must be filed within 10 days of injury.

Notice of Occupational Disease and Claim for Compensation. For conditions developing over time such as repetitive stress injuries, chemical exposure, or occupational illness.

Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation. For workplace injuries occurring during a single work shift.

Report of workplace injury or occupational disease filed with the state agency and insurer. Required within 3-10 days of injury depending on state. Establishes the claim in the system.

Florida's first report of injury or illness form. Employer must file within 7 days of knowledge of an injury or within 24 hours if the injury results in death.

Notice of Independent Medical Examination. Insurer-selected physician evaluates the claimant's condition. Worker must attend or risk benefit suspension.

Report from independent medical examiner regarding diagnosis, causation, treatment appropriateness, maximum medical improvement, and impairment rating.

Employee's claim for compensation filed with the NY Workers' Compensation Board. Must be filed within 2 years of the accident or within 2 years of when the claimant knew or should have known the condition was work-related.

Notice of Accident to Employer and Claim of Employee. Must be filed when injured on the job in North Carolina. Written notice to employer required within 30 days; claim filed within 2 years.

Notification to the state and worker that a rehabilitation professional has been assigned to assist with return-to-work planning.

Formal request to the workers' comp board to approve a settlement. May cover wage loss, medical benefits, or both.

Physician's initial and progress reports documenting diagnosis, treatment, work restrictions, and disability status. Form numbers vary by state (e.g., NY C-4, CA PR-2).

Employee's claim for compensation for a work-related injury or illness in Texas. Must be filed within one year of injury or within one year of when the employee knew or should have known the condition was work-related.

Referral for vocational rehabilitation services when an injured worker cannot return to previous employment. May include job retraining, education, or job placement services.

Request for approval of specific medical treatment, surgery, or diagnostic test related to a workplace injury. Insurer must respond within state-mandated timeframes.