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: 6/2024
Date of Last Review/Revision: 6/2024
Employee Concentration Supplement Application
Date of Last Review/Revision: 6/2024
Claims Kit
Date of Last Review/Revision: 6/2024
Date of Last Review/Revision: 6/2024
Date of Last Review/Revision: 6/2024
Health Questionnaire (Spanish)
Date of Last Review/Revision: 6/2024
Date of Last Review/Revision: 6/2024
Date of Last Review/Revision: 6/2024
WC-1 : Employers First Report of Injury
Date of Last Review/Revision: 7/2021
Date of Last Review/Revision: 12/2018
WC-207 : Release of Information…
Date of Last Review/Revision: 7/2021
WC-240 : Notice to Employee of Offer…
Date of Last Review/Revision: 7/2021
WC-BOR : Bill of Rights (English and Spanish)
Date of Last Review/Revision: 6/2024
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.
Workers’ Compensation with Health Care Mutual is a “Win-Win” proposition for your organization. Contact one of our independent agents, and let us become “your workers’ compensation partner.”