Forms
For your convenience, all forms on our website are in Adobe PDF Formatted Document Adobe® Acrobat® PDF format.
Policy Forms |
Date of Last Review/Revision |
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| Policy Holder Agreement | 6/2024 | ||
| Supplemental Application | 6/2024 | ||
| Employee Concentration Supplement Application | 6/2024 | ||
Claims Kit |
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| Statement of the Injured | 6/2024 | ||
| Reporting a Claim | 6/2024 | ||
| Health Questionnaire | 6/2024 | ||
| Health Questionnaire (Spanish) | 6/2024 | ||
| HCMCIC Contact Sheet | 6/2024 | ||
| Supervisors Report | 6/2024 | ||
| WC-1 : Employers First Report of Injury | 7/2021 | ||
| WC-6 : Wage Statement | 12/2018 | ||
| WC-207 : Release of Information... | 7/2021 | ||
| WC-240 : Notice to Employee of Offer... | 7/2021 | ||
| WC-BOR : Bill of Rights (English and Spanish) | 6/2024 | ||
| Request a new Panel of Physicians | (Will Open Email Form) |
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.
