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For your convenience, all forms on our website are in Adobe PDF Formatted Document Adobe® Acrobat® PDF format.

Policy Forms

Policy Holder Agreement
Supplemental Application (Updated 2017)
Surplus Note
Employee Concentration Supplement Application

Claims Kit

Statement of the Injured
Reporting a Claim
Health Questionnaire
Health Questionnaire  (Spanish)
HCMCIC Contact Sheet
Supervisors Report
WC-1 Employer's First Report of Injury (Revised 2017)
WC-6 Wage Statement (Revised 2017)
WC-207 Authorization and Consent to Release Information (Revised 2011)
WC-240 Notice to Employee of Offer of Suitable Employment (Revised 2014)
WC-BOR Bill of Rights (2018)
WC-P1 Panel of Physicians (2018)



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