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LIST OF FORMS CURRENTLY IN USE

  Petitions and forms available for downloading are highlighted.
(Updated November 2011)

** NEW FORMS:  the Board has adopted all new forms effective January 1, 2013 **

 

M-1 Practitioner's Report Eff 6/99 (Word 97)
M-1 Practitioner's Report (PDF)
M-2 Request for Independent Medical Examination Eff 6/99 (Word 97 format)
M-2 Request for Independent Medical Examination (PDF)
WCB-1 Employer's First Report of Injury Eff 1/02 (PDF)
WCB-1 Employer's First Report of Injury (Word 97)
WCB-2 Wage Statement Effective 06/11 (Word 97)
WCB-2 Wage Statement Effective 06/11 (PDF)
WCB-2A Schedule of Dependent(s) and Filing Status Statement Eff 8/94 (Word 97)
WCB-2A Schedule of Dependent(s) and Filing Status Statement (PDF)
WCB-2C Application for Waiver Eff 4/08 (Word 97)
WCB-2C Application for Waiver Eff 4/08 (RTF)
  Application for Waiver Instructions (Word 97)
WCB-3 Memorandum of Payment (Word 2003)
WCB-3 Memorandum of Payment (PDF)
WCB-4 Discontinuance or Modification of Compensation Eff 8/94 (Word 2003)
WCB-4 Discontinuance or Modification of Compensation (PDF)
WCB-4A Consent Between Employer and Employee Eff 10/11 (Word 2003)
WCB-4A Consent Between Employer and Employee Eff 10/11 (PDF)
WCB-6 Certificate Authorizing Release of Benefit Information Eff 3/97 (Word 97)
WCB-6 Certificate Authorizing Release of Benefit Information (PDF)
WCB-8 Certificate of Discontinuance or Reduction of Compensation Eff 8/94 (Word 2003)
WCB-8 Certificate of Discontinuance or Reduction of Compensation (PDF)
WCB-9 Notice of Controversy Eff 1/06 (Word 97)
WCB-9 Notice of Controversy Eff 1/06 (PDF)
WCB-9 Notice of Controversy Eff 10/98 (PDF)
WCB-10 Lump Sum Settlement Eff 3/98 (Word 2003)
WCB-10 Lump Sum Settlement (PDF)
WCB-11

Statement of Compensation Paid Eff 3/98 (Word 97)

WCB-25 Motion for Award of Fees and DisbursementsEff 5/93 (Word 97)
WCB-90 Notice to Workers (poster - last update 06/10) (PDF)
WCB-120 Petition for Review of Incapacity Eff 6/98 (Word 97)
WCB-121 Employee Petition for Review of Incapacity/Request for Provisional Order Eff 6/98 (Word 97)
WCB-122 Petition to Determine Average Weekly Wage Eff 6/98 (Word 97)
WCB-140 Petition for Award of Compensation Eff 6/98 (Word 97)
WCB-150  Petition for Award of Compensation - Fatal Eff 6/98 (Word 97) 
WCB-160 Petition for Award of Compensation - Occupational Disease Law Eff 6/98(Word 97) 
WCB-170 Petition for Restoration Eff 6/98 (Word 97)
WCB-171 Petition for Reinstatement Eff 6/98 (Word 97) 
WCB-180 Petition to Determine Extent of Permanent Impairment Eff 6/98 (Word 97)
WCB-190 Petition for Payment of Medical and Related Services Eff 6/98 (Word)
WCB-190A Provider's Petition for Payment of Medical and Related Services Eff 6/98 (Word 97)
WCB-195 Petition to Remedy Discrimination Eff 6/98 (Word 97)
WCB-220 Limited Certificate Authorizing Written Release of Medical/Health Care Information Eff 4/96 (Word 2003)
>WCB-221 Certificate Authorizing Release of Information Form no longer in use
WCB-230 Employment Status Report Eff 5/95 (Word 97)
WCB-231 Employee's Return to Work Report Eff 8/94 (Word 97)
WCB-231A Employee's Return to Work Report Rule 8.15 Eff 12/10 (PDF)
WCB-240 Notice of Intent to Appeal (PDF form-fillable)
WCB-250 Request for Expedited Proceeding Eff 8/94 (Word 2003)
WCB-260 Application for Predetermination of Independent Contractor Status to Establish Conclusive Presumption - Landowner/Woodharvester (Word 97)
WCB-260 Application for Predetermination of Independent Contractor Status to Establish Conclusive Presumption - Landowner/Woodharvester (PDF)
WCB-261 Application for Predetermination of Independent Contractor Status to Establish Rebuttable Presumption (Word 97) **no longer valid after 12/31/2012**
WCB-261 Application for Predetermination of Independent Contractor Status to Establish Rebuttable Presumption (PDF) **no longer valid after 12/31/2012**
WCB-262 Application for a Certificate of Independent Status (Word 97)
WCB-262

Application for a Certificate of Independent Status (PDF)

WCB-264 Application for Predetermination of Construction Subcontractor (RTF)**no longer valid after 12/31/2012**
WCB-264 Application for Predetermination of Construction Subcontractor (PDF)**no longer valid after 12/31/2012**
WCB-265 Application for Predetermination_Freight Courrier (PDF)Revised 11/7/2011 **no longer valid after 12/31/2012**
WCB-265 Application for Predetermination_Freight Courrier (RTF) Revised 11/7/2011 **no longer valid after 12/31/2012**
WCB-266 ** Effective 1/1/2013** Application for Predetermination of Independent Contractor Status to Establish A Rebuttable Presumption
Petition for Forfeiture (Word 97)

Application for Voc Rehab (Word 97)

  Complaint for Audit (Rich Text Format)
Waiver to request for Unemployment Information (Word 97) Available at any Regional Office

 

2011 Forms Manual
2011 Forms Manual Appendices

 

** Quantities may be reproduced locally or are available through Gossamer Press, Tel (207) 827-9881, Fax: (207) 827-9861