Department of Labor and Industry

Claims Assistance Forms

Claims Assistance Unit Forms

 

The forms listed below are those commonly used in the Claims Assistance Units Functions of the workers' compensation system.  You can use the following form to order these in quantity.  Order Form

First Report of Injury (FROI)

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

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.

Other Forms

Beneficiaries' Claim for Compensation

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 when initial compensability of a claim is denied. No recap sheet required.


Petition for Settlement - Injury/OD, Medical Benefits Reserved (also letter-size)
Used when settling wage loss entitlement, disputed wage loss entitlement & disputed perm total benefits and medical benefits are reserved.



Petition for Settlement - Injury/OD, Medical Closed on an Accepted Claim (also letter-size)
Used when settlement of medical is in best interest of parties or settling wage loss entitlement (other than Perm Total) and settlement of medical is in best interest of parties.



Petition for Settlement - Injury/OD, Disputed Medical Closed (also letter-size)
Used when settling wage loss entitlement & disputed perm total benefits and disputed medical benefits.



Petition for Settlement - PTD, Injury/OD Medical Benefits Reserved (also letter-size)
Used when settling perm total benefits and medical benefits are reserved.



Petition for Settlement - PTD, Injury/OD Medical Closed on an Accepted Claim (also letter-size)
Used when settling perm total benefits and settlement of medical is in best interest of parties.

Petition for Advance & Checklist for Advance Requirements