Workers' Compensation Forms Library
Here are the forms you need to manage your workers’ compensation insurance program. In addition to claim filing forms, you’ll find our pharmacy locator, workplace postings and injury prevention forms.
The forms linked here are in Portable Document Format (PDF), that requires them to be downloaded and printed using Adobe Acrobat software. If you do not have Adobe Acrobat Reader, you can immediately obtain this free here.
Claim Forms by State
- Claim Kit - MA
- Employer's First Report of Injury or Fatality (Form 101)
- Industry Reference Code (Form 101)
- Average Weekly Wage Computation Schedule (Form 127)
- Request for Medical Services
- A.I.M. Vantage Primary Injury Treatment Centers
- Medical Release for Injured Workers (MA)
- Med-Fax Report (Medical only claims - do not file this form with the Department of Industrial Accidents)
- Claim Kit - NH
- Notice of Accidental Injury or Occupational Disease (Form 8aWCA)
- Employers First Report of Occupational Injury or Disease (8WC)
- Employer's Supplemental Report of Injury (13WCA)
- Wage Schedule (76 WCA)
- Supplemental Employee Forms - Lost Time Only
- Medical Release for Injured Workers (NH)
- A.I.M. Vantage Occupational Health Centers
- NH Task Analysis Form
- NH Second Injury Fund Employee Information Sheet (Optional)
- Claim Kit - CT
- Employer's First Report of Occupational Injury or Illness
- Filing Status and Exemption (Form 1A)
- Employee Medical and Work Status
- HIPAA Release
- Corvel PPO Lookup
- Connecticut Managed Care Preferred Provider for Employers
- CT Primary Care Facility Poster (Spanish)
- CT Notice to Employees (Spanish)
- Claim Kit - VT
- Form 1- Employer First Report of Injury
- Form 7- Workers' Compensation Medical Authorization
- Form 8- Notice of Intent to Change Healthcare Provider
- Form 10- Certificate of Dependency and Concurrent Employment
- Form 25- Wage Statement
- Form 4- Report of Fatal Accident
- A.I.M. Vantage Primary Injury Treatment Centers
Additional Forms
