Claim 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 software at: www.adobe.com/products/acrobat/readstep2.htm

Massachusetts

Claim Kits - MA

A.I.MWorks Med-Fax form - this is a medical-only form do not file with the Department of Industrial Accidents

Documents Required to File a Lost Time claim - MA

Employer's First Report of Injury or Fatality (Form 101)

Industry Reference Code (Form 101)

Average Weekly Wage Compensation Schedule (Form 127)

Supplemental Employee Forms - lost time only

Medical Release for Injured Workers

New Hampshire

Claim Kit - New Hampshire

Documents Required to File a Medical Only claim - NH

Employer's First Report of Occupational Injury or Disease (Form 8WC)

Notice of Accidental Injury or Occupational Disease (Form 8aWCA)

Documents Required to File a Lost Time Claim - NH

Employer's First Report of Occupational Injury or Disease (Form 8WC)

Employer's Supplemental Report of Injury (13WCA)

Supplemental Wage Schedule (76WCA) 

Supplemental Employee Form (Lost Time Only) 

Medical Release for Injured Workers

Additional Information - MA and NH

A.I.M.Works Worksite Poster- all MA companies

A.I.M.Works Worksite Poster - NH

BDOHI Affiliated Primary Occupational Health Centers 

New Hampshire Employers Guide to BDOHI

Express Scripts Pharmacy Network

A.I.M. Express Scripts Temporary Prescription Services I.D.

AIS, LLC Express Scripts Temporary Prescription Services I.D.

Stay at Work/Return to Work™ Forms

Connecticut

Claim Kit-Connecticut

Employer's First Report of Occupational Injury or Illness

Filing Status and Exemption (Form 1A)

Employee Medical and Work Status

HIPAA Release

Connecticut Managed Care for Employers

Corvel PPO Lookup

Express Scripts Pharmacy Network