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Carrier Attorney/Insurer/TPA/Self-Insured Employer Forms Available For Upload
| Form ID | Description |
|---|---|
| C-107 | EMPLOYERS Request for Reimbursement |
| C-240 | Employer's Statement of Wage Earnings Preceding the Date of Accident |
| C-256.2 | State Insurance Fund - Claim for Reimbursement of Wages Paid |
| C-258 | Claimant's Record of Job Search |
| C-258.1 | Injured Worker's Record of Independent Job Search Efforts |
| C-300.5 | Stipulation |
| C-32 | Settlement Agreement - Section 32 |
| C-32.1 | Claimant release form/Section 32 |
| C-32-I | Section 32 agreement -Indemnity only |
| C-4 | Doctor's Initial Report |
| C-4.1 | Continuation to Carrier/Employer Billing Portion of Form C-4 |
| C-4.2 | Doctor's Progress Report |
| C-4.3 | Doctor's Report of MMI/Permanent Impairment |
| C-4/C-48 | Attending Doctor's Report |
| C-4AMR | Ancillary Medical Report |
| C-5 | Attending Ophthalmologist's Report |
| C-62 | Claim for Compensation in Death Case |
| C-64 | Proof of Death by Physician Last in Attendance on Deceased |
| C-65 | Proof of Burial and Funeral Expenses by Undertaker |
| CORR | Correspondence |
| DEATH-CERT | Death Certificate |
| DEPOSITION | Deposition |
| EXHIBIT | Exhibit (Medical or Other) |
| FCE-4 | Practitioner's Report of Functional Capacity Examination |
| MED-NARR | Medical Report |
| MEMO-OF-LAW | Memorandum of Law |
| OT/PT4 | Occupational/Physical Therapist's Report |
| PH-16.2 | Pre-Hearing Conference Statement |
| PS-4 | Psychologist's Report |
| REIB-REQUEST | Reimbursement Request |
Available Documents for Injured Workers/Claimants
Available Documents for Claimant Attorneys/Licensed Representatives
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