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Governor Eric J. Holcomb
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Forms

Below is a list of all the State Forms for the Worker's Compensation Board listed in numerical order. You may click the form name or the form number to download a fillable PDF version. If you cannot locate a form or wish to search for one specifically, please use the search tool found here.

To find the Self-Insurance forms, please click here.

Information about the 2nd Injury Fund and it's associated forms, please click here.

State Form NameForm Number
Application for Review by Full Board1042
Agreement to Compensation1043
Physician's Report2118
Provider Fee Application for Adjustment of Claim18487
Agreement to Compensation Between the Dependents of Deceased Employee and Employer18875
Application for Adjustment of Claim29109
First Report of Injury**34401
Agreement Between Parties for Lump Sum Payment34873
Subpoena34877
Notice for Worker's Compensation and Occupational Diseases Coverage**36097
Report Of Temporary Total Disability (TTD)/Temporary Partial Disability (TPD) Termination**38911
Request for Assistance45442
Application for Worker's Compensation Clearance Certificate (English)45889
Application for Worker's Compensation Clearance Certificate (Spanish)55718
Notice of Inability to Determine Liability / Request for Additional Time**48557
Application for Second Injury Fund Benefits51247
Request for Prosthetic Repair or ReplacementTBD
Provider Fee Request for Assistance52875
Request for Public Record53811
Employee Waiver of Examination by Personal Physician53913
Notice of Denial of Benefits**53914
Notice of Suspension of Compensation and/or Benefits54217
Certification of Insurance Carrier as to Number of Worker's Compensation Policies Written or Renewed55310
Summary of Benefits PaidTBD

**Please note that all forms marked by an asterisk are required to be submitted electronically via an approved EDI 3.1 process. Forms submitted to the Board in hard copy prior to being submitted electronically will be rejected.