Forms
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) |
NOTE: You must have the Adobe® Acrobat® Reader installed on your computer in order to view and print these forms. This is a free program. Click the link below for more information.
