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Workers’ Compensation Board

WCB Information Related To Novel Coronavirus (COVID-19)

List of Available Forms for Insurance Carriers, Self Insured Employers and Third Party Administrators

These forms are available for completion and online submission through the Board's web site. To access a form, select the form number or title. If registration is required, a login screen will prompt you for your user ID and password. Complete the online application to register for Web Submission of Claim Forms.

After the Board receives your form, a non-editable PDF version of the form will appear in your web browser. The first page contains a confirmation that your form was successfully submitted to the Board and the date. It should be saved for your records. DO NOT MAIL THIS FORM TO THE BOARD.

Form Instructions

Forms Submitted by Insurance Carriers, Self-Insured Employers and Third Party Administrators
Form Number Form Title Registration required? Comments
C-8.1 Notice of Treatment Issue(s)/ Disputed Bill Issue(s) Yes Treatment issue: within 5 days after terminating medical care or refusing authorization.

Disputed bill: within 45 days of submission of bill.
DB-470 Preliminary/Final Claim for Reimbursement of Benefits Paid Under Disability Benefits Law Yes Submitted prior to award of workers' compensation benefits.
PH-16.2 Pre-Hearing Conference Statement No Filed ten days before scheduled pre-hearing conference for controverted cases (FROI-04/SROI-04).
RFA-2 Request for Further Action By Carrier/Employer No The form may be filed at any time after the indexing of a claim or after the Board has indicated that no further action (NFA) will be taken. REPLACES FORMS C-89.3, C-22B, CB-8 AND RB-679.

Note: When filing required documents (e.g. medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder.

If the form you are looking for is not available for online submission, you may print the PAPER version of the form from our list of common forms.