Instructions for downloading:

1. The sections are separated by categories and forms that pertain to that section are listed in the boxes.
2. When you locate the form you need, click on the icon for the specific format to download the form.
3. The formats are for Microsoft Word, for Microsoft Excel, or for Adobe PDF.

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*Note: To Use Fillable Forms

When opening fillable forms, right click and choose Save As. Save the form on your computer. Fill out the form, save, and submit to Clerk of the Court.

Legal Forms - Mandatory

Please select the form and click on the link to download. Mandatory forms are rule-based forms.

Mandatory Forms

Application to Director
Application to Workers' Compensation Judge
Complaint with Two Employers/Insurers
Health Care Provider (HCP) Disagreement Form
Informal Response
Joint Request for Expedited Section 52-5-12 Hearing
Notice of Acceptance or Rejection of Recommended Resolution
Notice of Telephonic Conference Code
Petition for Lump Sum Payment
Request for Setting

Mandatory Forms (Continued)

Subpoena
Summons for Application to Director
Summons for Application to Workers' Compensation Judge
Summons for Petition for Lump Sum Payment
Summons for Workers' Compensation Complaint
Summons for Uninsured Employers' Fund (UEF) Complaint
Uninsured Employers' Fund (UEF) Complaint
Worker's Authorization for Use and Disclosure of Health Records (HIPAA)
Worker's Compensation Complaint

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Legal Forms - Optional

Please select the form and click on the link to download.

Optional Forms

Additional Page if Needed
Change of Address
Form Letter to Health Care Provider
Joint Waiver of Disqualification
Notice of Change of Health Care Provider
Notice of Disqualification

Optional Forms (Continued)

Out of State Health Care Provider Affidavit/Order Granting Approval
ProSe Consent
ProSe Revocation
Request for Late Reset of Mediation Conference
Stipulated Recommended Resolution
Worker's Response

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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.

Please select the form and click on the link to download.

Packets

Application to Director Packet
Application to Workers' Compensation Judge Packet
Lump Sum Payment Packet
Out of State Health Care Provider Packet
Workers' Compensation Complaint Form Packet
Uninsured Employers' Fund (UEF) Packet

Miscellaneous Forms

Affidavit of Annual Safety Inspection
Notice of Accident
Notice of Accident in two parts (download both pieces)
Report Fraud

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Insurance Forms

Please select the form and click on the link to download.

Coverage

Election to be Subject
Executive Employee Affirmative Election
Revocation of Prior Election

Self-Insurance

Amendatory Endorsement
Application - Individual
Application - Group
Board of Directors Resolution
Letter of Credit - Individual
Letter of Credit - Group
Parental Guaranty for Subsidiaries
Surety Bond - Individual
Surety Bond - Group

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Data Reporting

Please select the form and click on the link to download.

Reporting Forms

EDI Trading Partner Profile: E7
Inpatient Medical Data: E9
Proof of Coverage Sender/Vendor Information: P7
Proof of Coverage Insurer Information: P8

Medical Forms

Approval of Out of State HCP Letter
Request for Billing Disputes, Case Management and UR
Notice of Inpatient Admission
Provider's Report of Physical Ability (PROPA)
Release for Health Care Records (HIPAA)