Forms Library

Use this link to complete a card that the injured employee can use to avoid paying out of pocket for medications related to the injury. Learn more about Pharmacies >

Use this form to offer a panel of physicians to the injured worker. Learn more about Physician Panels >

Use this form to request Return to Work services. Learn more about the Return to Work program >

Use this form to evaluate the Injured Worker's job and the physical demands needed to complete it. Learn more about Physical Capabilities Evaluation >

Use this optional form any time there is a change in the injured worker’s work status which results in lost time or return to work and will affect the amount of indemnity benefits the injured worker is owed.  Learn more about Reporting an Injury >

Use this form to add or make changes to agency contacts and system access information.

This form is used exclusively for mileage reimbursement.

Complete this form when the injured worker has out of pocket expense for medical care or approved pharmacy prescriptions.

Use these checklists to arm you with the most common types of information the benefit coordinator will need in order to complete their investigation.