Master Policy Number
WC008-000001-124 – Applicable for the following states: AL, FL, GA, IA, IL, IN, KY, MD, MI, MO, MS, NC, SC, TN, TX, VA, WV
WC080-000001-124 – Applicable for the following states: AR, CO, DC, DE, HI, KS, ME, MT, NE, NM, NV, OK, RI, UT, VT
If you do business in one or more Multiple Coordinated Policy (MCP) states, a unique policy number for each MCP state will be assigned to you.
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Download the forms on this page and fill them out using your PDF reader.
General Forms
Catastrophic Claim
Reporting Instructions
Incident Investigation Checklist
Employers Report of Incident
Employers Report of Incident (Spanish)
Employee’s Report of Incident
Witness Statement
Refusal of Doctor Care
Light-Duty Templates
Light-Duty Sample Letter 1
Light-Duty Sample Letter 2
Light-Duty Job Offer Sample
Authorization for Medical Treatment & Pharmacy First Fill
Click the link below to download the Authorization for Medical Treatment & Pharmacy First Fill.
Click Here for Version 1 – For injured workers in AL, FL, GA, IA, IL, IN, KY, LA, MD, MI, MO, MS, NC, NJ, PA, SC, TN, TX, VA, WI, WV
Click Here for Version 2 – For injured workers in AR, AZ, CO, CT, DC, DE, HI, ID, KS, MA, ME, MN, MT, NE, NM, MT NE, NM, NV, OK, RI, SD, UT, VT
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