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Forms
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Forms
Workers' Compensation
WC-1
Employer's Report of Industrial Injury
Instruction Sheet
WC-2
Physician's Report
WC-2
Test
WC-2 Test Form
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Attachment A
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Attachment B
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Instructions
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Memo
WC-5
Employee's Claim for Workers' Compensation Benefits
WC-5A
Dependents' Claim for Compensation
WC-14
Employee's Wage Report
WC-21
Application for Self-Insurance Auth.
WC-42
Request for Information or Photo Copies
WC-77
Application for Hearing
WC-77A
Response to Application for Hearing
DC-AB1
Request for Approval of Attorney's Fee
Temporary Disability Insurance
TDI-14
Equivalency Tables
TDI-15
TDI Self-Insurer's Plan Certification & Agreement
Prepaid Healthcare
HC-4
Health Care Coverage Questionnaire
HC-5
Employee Notification to Employer
2012
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2011
HC-6
Small Employers Subject To PHC / Employer's Request for Premium Supplementation
HC-7
Application for Plan Review
HC-61
Application For Self-Insurance Auth
General Forms
DC-54
Complaint Form
LIR#27
Application for Certificate of Compliance with Section 3-122-112, HAR
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