Instructions for downloading:

1. The sections are separated by categories and forms that pertain to that section are listed in the boxes.
2. When you locate the form you need, click on the icon for the specific format to download the form.
3. The formats are document for Microsoft Word, Excel for Microsoft Excel, or pdf for Adobe PDF.

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*Note: To Use Fillable Forms

When opening fillable forms, right click and choose Save As. Save the form on your computer. Fill out the form, save, and submit to Clerk of the Court.

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Legal Forms - Mandatory

Please select the form and click on the link to download. Mandatory forms are rule-based forms.

Mandatory Forms

Application to Director  document  pdf
Application to Workers' Compensation Judge   document  pdf
Complaint with Two Employers/Insurers   document  pdf
Health Care Provider (HCP) Disagreement Form  document  pdf
Informal Response document  pdf
Joint Request for Expedited Section 52-5-12 Hearing  document  pdf
Notice of Acceptance or Rejection of Recommended Resolution  document  pdf
Notice of Telephonic Conference Code   pdf
Petition for Lump Sum Payment  document  pdf
Request for Setting  document  pdf

Mandatory Forms (Continued)

Subpoena document  pdf
Summons for Application to Director   document  pdf
Summons for Application to Workers' Compensation Judge  document pdf
Summons for Petition for Lump Sum Payment  document  pdf
Summons for Workers' Compensation Complaint  document  pdf
Summons for Uninsured Employers' Fund (UEF) Complaint document pdf
Uninsured Employers' Fund (UEF) Complaint  document  pdf
Worker's Authorization for Use and Disclosure of Health Records (HIPAA)   document  pdf
Worker's Compensation Complaint  document  pdf

Legal Forms - Optional

Please select the form and click on the link to download.

Optional Forms

Additional Page if Needed    pdf
Change of Address document  pdf
Form Letter to Health Care Provider  document  pdf
Joint Waiver of Disqualification  document  pdf
Notice of Change of Health Care Provider  document  pdf
Notice of Disqualification  document  pdf

Optional Forms (Continued)

Out of State Health Care Provider Affidavit/Order Granting Approval  document  pdf
ProSe Consent document  pdf
ProSe Revocation document  pdf
Request for Late Reset of Mediation Conference pdf
Stipulated Recommended Resolution pdf
Worker's Response  document  pdf

Legal Forms - Packets

Notice: Forms found in packets are put together so that filers know what forms are needed. Despite forms being together in a packet, when e-filing, forms must be filed individually.

Please select the form and click on the link to download.


Application to Director Packet  pdf
Application to Workers' Compensation Judge Packet  pdf
Lump Sum Payment Packet  pdf
Out of State Health Care Provider Packet  pdf
Workers' Compensation Complaint Form Packet  pdf
Uninsured Employers' Fund (UEF) Packet  pdf

Miscellaneous Forms

Affidavit of Annual Safety Inspection   pdf 
Notice of Accident   pdf
Notice of Accident in two parts (download both pieces)   pdf
Report Fraud   pdf

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Insurance Forms

Please select the form and click on the link to download.


Election to be Subject  pdf
Executive Employee Affirmative Election  pdf
Revocation of Prior Election   pdf



Amendatory Endorsement  document
Application - Individual  document 
Application - Group  document 
Board of Directors Resolution  document  
Letter of Credit - Individual  document 
Letter of Credit - Group  document
Parental Guaranty for Subsidiaries  document 
Surety Bond - Individual  document
Surety Bond - Group  document

Data Reporting

Please select the form and click on the link to download.

Reporting Forms

EDI Trading Partner Profile: E7   pdf
Inpatient Medical Data: E9   pdf
Proof of Coverage Sender/Vendor Information: P7   pdf
Proof of Coverage Insurer Information: P8   pdf 

Medical Forms

Approval of Out of State HCP Letter  pdf
Request for Billing Disputes, Case Management and UR  pdf 
Notice of Inpatient Admission pdf
Provider's Report of Physical Ability (PROPA)  pdf
Release for Health Care Records (HIPAA) document  pdf
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