Department of Labor and Industry

Workers' Compensation-Related Forms

The forms listed below are those commonly used in the Employment Relations functions of the workers' compensation system. You can use the following form to order these in quantity. Order Form

FIRST REPORT OF INJURY (Revised 04/09)

Legal size form recommended for those who wish to complete on a typewriter or long hand.
Letter size form this form is in WORD form format for those who wish to complete it on their computer.

FROI Instructions

  • Simply tab through the fields to complete the form
  • Used by an injured worker to report an injury or occupational disease to his/her employer
  • Used by an employer to report an injured worker's injury or occupational disease to the employer's insurer/adjuster
  • Used by an insurer/adjuster to report claim data to the Department

Subsequent Report of Injury
Used by insurer/adjuster to report on-going claim data to the Department.

Third Party Agent/Adjuster Change Form
Used to report changes in adjuster, claim administrators, or third party administrators.

Third Party Administrator Profile
Used for adding new Third Party Administrators (TPA) and for changes to contact information for existing TPAs .

ELECTRONIC DATA INTERCHANGE (EDI) FORMS

Used by insurers and adjusters as a quick, efficient method of communicating data to the Department.

Petition for Workers' Compensation Mediation Conference
Used by and injured worker or and adjuster or insurer to request a mediation conference in order to resolve a dispute over workers' compensation benefits.

Medical Providers Billing Request Form
Used by a medical provider to obtain from the Department sufficient information to send an injured worker's medical bill to the proper insurer or adjuster.

Electronic Prior Claims (EPC) History Access Agreement
Used by an insurer to obtain access to the EPC system in order to obtain prior claim history on their claimants.

Attorney Retainer Document
Used by an attorney to formalize fee contract with an injured worker.

Petition for Settlement - Disputed Initial Comp & Checklist for Settlement Requirements
Used by insurer/adjuster when parties have agreed to compromise and settle disputes on a claim. Used when initial compensability of a claim is disputed. No recap sheet required.

Petition for Settlement - Injury/OD - Medical Reserved & Checklist for Settlement Requirements
Used by an insurer/adjuster when parties have agreed to a compromise and release settlement of the claim.

Petition for Settlement - Injury/OD - Medical Closed & Checklist for Settlement Requirements

Petition for Settlement - PTD & Checklist for Settlement Requirements

Petition for Advanced & Checklist for Settlement Requirements

Settlement/Advance Recap Sheet & Recap Sheet Instructions
Used by insurer/adjuster, in conjunction with a petition for Settlement or request for lump sum payment.

OTHER FORMS

Beneficiaries' Claim for Compensation

Physician's Referral to Domiciliary Care

Subsequent Injury Fund Forms