WORKERS' COMPENSATION CLAIM FORMS
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
NEVADA WORKERS' COMPENSATION CLAIMS FORMS
C-1 Notice of Injury or Occupational Disease
C-3 Employers Report of Industrial Injury or Occupational Disease
C-4 Employees Claim for Compensation Report Initial Treatment Form
D-1 Nevada Workers Compensation Information Poster
D-8 Employers Wage Verification Form
D-26 Application for Reimbursement of Claim Related Travel Expenses
WORKERS' COMPENSATION UNDERWRITING FORMS
Agriculture Employees
Application for Insurance
Application for Insurance (Español)
Cancellation Request
Contractor Supplemental Application
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