Forms
Legal Forms – Mandatory
- Application to Director (pdf)
- Application to Director (Docx)
- Application to Workers’ Compensation Judge (pdf)
- Application to Workers’ Compensation Judge (Docx)
- Complaint with Two Employers/Insurers (pdf)
- Complaint with Two Employers/Insurers (Docx)
- Health Care Provider (HCP) Disagreement Form (pdf)
- Health Care Provider (HCP) Disagreement Form (Docx)
- Informal Response (pdf)
- Informal Response (Docx)
- Joint Request for Expedited Section 52-5-12 Hearing (pdf)
- Joint Request for Expedited Section 52-5-12 Hearing (Docx)
- Notice of Acceptance or Rejection of Recommended Resolution (pdf)
- Notice of Acceptance or Rejection of Recommended Resolution (Docx)
- Notice of Telephonic Conference Code (pdf)
- Petition for Lump Sum Payment (pdf)
- Petition for Lump Sum Payment (Docx)
- Request for Setting (pdf)
- Request for Setting (Docx)
- Subpoena (pdf)
- Subpoena (Docx)
- Summons for Application to Director (pdf)
- Summons for Application to Director (Docx)
- Summons for Application to Workers’ Compensation Judge (pdf)
- Summons for Application to Workers’ Compensation Judge (Docx)
- Summons for Petition for Lump Sum Payment (pdf)
- Summons for Petition for Lump Sum Payment (Docx)
- Summons for Workers’ Compensation Complaint (pdf)
- Summons for Workers’ Compensation Complaint (Docx)
- Summons for Uninsured Employers’ Fund (UEF) Complaint (pdf)
- Uninsured Employers’ Fund (UEF) Complaint (pdf)
- Uninsured Employers’ Fund (UEF) Complaint (Docx)
- Workers’ Authorization for Use and Disclosure of Health Records (HIPAA) (pdf)
- Workers’ Authorization for Use and Disclosure of Health Records (HIPAA) (Docx)
- Workers’ Compensation Complaint (pdf)
- Workers’ Compensation Complaint (Docx)
Formas Legales – Obligatorias
Legal Forms – Optional
- Additional Page if Needed (pdf)
- Change of Address (pdf)
- Change of Address (Docx)
- Form Letter to Health Care Provider (pdf)
- Form Letter to Health Care Provider (Docx)
- Joint Waiver of Disqualification (pdf)
- Joint Waiver of Disqualification (Docx)
- Notice of Change of Health Care Provider (pdf)
- Notice of Change of Health Care Provider (Docx)
- Notice of Disqualification (pdf)
- Notice of Disqualification (Docx)
- Out of State Health Care Provider Affidavit (pdf)
- Out of State Health Care Provider Affidavit (Docx)
- ProSe Consent (pdf)
- ProSe Consent (Docx)
- ProSe Revocation (pdf)
- ProSe Revocation (Docx)
- Request for Late Reset of Mediation Conference (pdf)
- Stipulated Recommended Resolution (pdf)
- Worker’s Response (pdf)
- Worker’s Response (Docx)
- Pre Litigation Report (pdf)
Legal Forms – Packets
Notice: Forms found in packets are put together so that filers know what forms are needed. Despite forms being together in a packet, when e-filing, forms must be filed individually.
Formularios Legales – Paquetes
Aviso: Los formularios que se encuentran en los paquetes se preparan para que los contribuyentes sepan qué formularios se necesitan. A pesar de que los formularios están juntos en un paquete, cuando se presenta electrónicamente, los formularios deben presentarse individualmente