WORKERS' COMPENSATION CLAIM FORMS

File a Claim Online
Direct Deposit Online Form (English and Spanish)

UTAH WORKERS' COMPENSATION CLAIM FORMS

Restorative Services Authorization/Denial - Form 221a - Spine
Restorative Services Authorization/Denial - Form 221b - Upper Extremity
Restorative Services Authorization/Denial - Form 221c - Lower Extremity

CALIFORNIA WORKERS' COMPENSATION CLAIMS FORMS

Form 5020 – Employers First Report of Occupational Injury
Guide of First Aid, Medical Only, and Indemnity Claims
WCF Information Page
California MPN Information for your workplace
New Employee Time of Hire Pamphlet – English
New Employee Time of Hire Pamphlet – Spanish
Information & Assistance List (I&A Offices by location)
Important Information about Medical Care – English
Important Information about Medical Care – Spanish
DWC-1 Claim Form
California Workers' Compensation Fact Sheet

WORKERS' COMPENSATION UNDERWRITING FORMS

Agriculture Employees
Application for Insurance
Application for Insurance (Español)
Authorization Agreement for Automatic Payment
Cancellation Request
Termination Notice for Automatic Payments
General Business Supplemental Questionnaire
General Business Supplemental Questionnaire (Español)
Dairy Supplemental Questionnaire
Contractor Executive Supervisor Questionnaire
Policy Review Form
Policy Review Form (Español)
Aviation Questionnaire
Trucking Questionnaire
Trucking Questionnaire (Español)
Arizona Alcohol-and Drug-Free Workplace Premium Credit
The Idaho Alcohol and Drug-Free Workplace Certification Form
Request for Ownership (ERM 14)

UTAH WORKERS' COMPENSATION UNDERWRITING FORMS

Waiver of Subrogation
Waiver of Subrogation (Español)

UTAH ASSOCIATION AGREEMENTS

Associated Builders and Contractors (ABC) of Utah Participation Agreement
Associated General Contractors (AGC) of Utah Participation Agreement
Utah Home Builders Association (HBA) Participation Agreement
Utah Manufacturers Association (UMA) Participation Agreement
Utah Restaurant Association (URA) Participation Agreement
Utah Roofing Contractors Association (URCA) Participation Agreement
Utah Trucking Association (UTA) Participation Agreement
Pre-Approved Safety Courses for Association Credit

UTAH LABOR COMMISSION FORMS

OSHA Required Form