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Claimant/Injured Worker Forms Available For Upload
| Form ID | Description |
|---|---|
| C-257 | Claimant's Record of Medical-Travel Expenses |
| 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-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 |
| CLMT-CORR | Claimant Correspondence |
| DEATH-CERT | Death Certificate |
| EXHIBIT | Exhibit (Medical or Other) |
| FCE-4 | Practitioner's Report of Functional Capacity Examination |
| MED-NARR | Medical Report |
| OT/PT4 | Occupational/Physical Therapist's Report |
| PS-4 | Psychologist's Report |
Available Documents for Claimant Attorneys/Licensed Representatives
Available Documents for Insurer Attorney/TPAs/Self-Insured Employers/Carriers
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