State Forms

Workers' Compensation

• WC-1 Employer's Report of Industrial Injury
• Instruction Sheet
• WC-2 Physician's Report
• WC-5 Employee's Claim for Workers' Compensation Benefits
• WC-5A Dependents' Claim for Compensation
• WC-14 Employee's Wage Report
• WC-21 Application for Self-Insurance
• WC-42 Request for Information or Photo Copies
• WC-77 Application for Hearing
• WC-77A Response to Application for Hearing
• Request for Approval of Attorney's Fee

Temporary Disability Insurance (TDI)

For employees:

Claim forms are not available online. Ask your employer for a claim form or contact us if your employer does not have the claim form.

FOR EMPLOYERS:

• TDI-14 Equivalency Tables
• TDI-15 TDI Self-Insurer's Plan Certification & Agreement
  
  

Prepaid Healthcare (PHC)

• HC-5 Employee Notification to Employer: 2021

For employers:

• HC-4 Health Care Coverage Questionnaire
• HC-6 Small Employers Subject To PHC / Employer's Request for Premium Supplementation
• HC-61 Application For Self-Insurance Auth
  
  

For Health care Contractors:

• HC-7 Application for Plan Review
• HC-7(a-1) “Reimbursement” type plans (A summary of benefits of the prevalent PPO plan.)
• HC-7(a-2) “Service” type plans (A summary of benefits of the prevalent HMO plan.)
  
  

General Forms

• DC-54 Complaint Form
• LIR#27 Application for Certificate of Compliance with Section 3-122-112, HAR