Claims Info and Forms/Checklists
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Accident Reporting Checklist
AZ Minimum Wage Act Poster – Spanish
Claim Form – Oregon – Spanish
DOWC Insurance Requirements Brochure – Colorado
Employee Safety and Health Protection – Arizona
Employee’s Claim for Workers’ Compensation Benefits DWC-1
Employers Report of Industrial Injury Form ICA-04-0101
Employers Report of Injury – Colorado
Employers Report of Injury – Nevada
Employers Report of Injury – Oregon
Employers Report of Injury – Utah- First Report of Injury Form 5020
Information for Employers for Workers’ Compensation – Nevada
Information for Injured Workers – Nevada
Information for Injured Workers – CO (Spanish)
Medical Service Order form California
Medical Services Order Form – Not California- Medical Services Order Form – Not California
Minimum Wage Act Poster
MPN Distribution Acknowledgement
Nevada Alternate Choice of Physician
Nevada ER Wage Verification Form
Nevada Fatality Report
Nevada Notice to Employees
Notice of Injury or Occupational Disease – Nevada
Notice to Employees – Arizona- Notice to Employees Poster for Injuries Cause on the Job (DWC 7)
TeleCompCare® Wallet Card Sample – Spanish
Time of Hire Pamphlet – English
Time of Hire Pamphlet – Spanish
WalkSafe: Accident Investigation Report Form
Work Exposure to Bodily Fluids – Arizona
Work Exposure to MRSA – Arizona
Workers Report of Injury – Arizona
Workers’ Compensation Temporary Prescription ID Card
