Forms

Form WC-100-Employer’s Basic Report of Injury: Employer shall report immediately all injuries, including diseases, which arise out of and in the course of employment, or on which a claim is made and result in any of the following: (a) disability extending beyond 7 consecutive days, not including the date of injury, (b) death, (c) specific loss.

  • Copy to be provided to employee.
  • Filing of Notice of Dispute Form WC-107 tolls filing of Form WC100.
  • Form WC-106—Supplemental Report of Fatal Injury: Immediately upon death of injured employee.
    • Copy to be provided to dependent.
  • Form WC-107—Notice of Dispute: On or before the 14th day after the employer has notice or knowledge of an alleged injury or death, a carrier shall notify the Agency, if the right of the injured employee or dependent to compensation is disputed. Medical report should be attached.
    • Copy sent to employee or dependent.
  • Form WC-110—Report of Rehabilitation: 3 months after the date of injury and after each subsequent 4 months, what evaluation and what provision has been made for rehabilitation on all cases for which a final Form WC-701 has not been filed. All reports should be accompanied by medical report.