Claims center

Download KeyScripts temporary prescription benefits card

• Form 7 Employee's Notice of Accidental Injury or Occupation Disease
• Form 7A Employee's Claim Application
• Form 8 Employer's First Report of Injury or Occupational Disease

• Form DWC-1 First Report of Injury or Illness
• Form DWC 1a Wage Statement
• Form DWC 3 Request for Wage Loss/Temporary Partial Benefits

• Form WC-1 Employer's First Report of Injury or Occupational Disease
• Form WC-6 Wage Statement
• Form WC-2 Notice of Payment or Suspension of Benefits
• Form WC-104 Notice to Employee of Medical Release to Return to Work with Restrictions or Limitations

• Form 1A-1 Workers Compensation – First Report of Injury or Illness
• Form C-2 Statement of Wage Information
• Form C-06 Insurer's Termination of Temporary Total Disability Benefits

• Form IAIABC IA-1 First Report of Injury or Illness

• Form 19 Employer's Report of Employees Injury or Occupational Disease to the Industrial Commission
• Form 22 Statement of Days Worked and Earnings of Injured Employee
• Form 25T Itemized Statement of Charges for Travel
• Form 28 Return to Work Report
• Form 28T Notice of Termination of Compensation by Reason of Trial Return to Work

• Form 12A First Report of Injury or Illness
• Form 20 Statement of Earnings of Injured Employee

• Form C-20 Employer's First Report of Work Injury or Illness
• Form C-41 Wage Statement
• Form C-42 Employee's Choice of Physician

• Form 3 Employer's Accident Report
• Form 7A Wage Chart