EMPLOYER FORMS

• Arizona Claims Kit

• Arizona First Report of Injury

• Arizona Notice to Employees to Reject Comp

• Arizona Work Exposure to Bodily Fluids Poster – English

• Arizona Work Exposure to Bodily Fluids Poster – Spanish

• Arizona Work Place Safety Poster

• Arizona Workers Report

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California Department of Industrial Relations Workers’ Compensation Forms >>

EMPLOYER FORMS
Facts about Workers’ Compensation English / Spanish
Notice of Employee Death – (DIA 510)
Mileage Request Form

POLICY HOLDER KIT
Employers First Report of Injury – (5020)
Employee Claim Form – (DWC1)
Workers’ Compensation Poster Notice to Employees (DWC7) English / Spanish
Fraud Reward Poster English / Spanish
Time of Hire Pamphlet English / Spanish

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• Illinois Claims Kit

• Illinois Posting Notice

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EMPLOYER FORMS

• Nevada Claims Kit

• Nevada Employee Rights Poster

• Nevada Employers First Report of Injury

• Posting Requirements for the Nevada

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• North Carolina Claims Kit

• North Carolina First Report of Injury

• North Carolina Posting Notice – English

• North Carolina Posting Notice – Spanish

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EMPLOYER FORMS

• Oregon Claims Kit

• Oregon First Report of Injury – English

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• Oregon Posting Notice – English

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• Oregon Workers Guide – English

• Oregon Workers Guide – Russian

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• Oregon Workers Guide – Vietnamese

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EMPLOYER FORMS

• Tennessee Choice of Physician Agreement – English

• Tennessee Choice of Physician Agreement – Spanish

• Tennessee Claims Kit

• Tennessee Epilepsy Waiver

• Tennessee First Report of Injury

• Tennessee Heart Waiver

• Tennessee Occupational Disease Waiver

• Tennessee Posting Notice – English

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EMPLOYER FORMS
Claim Administration Contact:
Sue Cooper
TOL (866) 825-9891 X24218

• HCN Forms / Texas HCN Compkey Enrollment Documents

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• Covered Employee Notification of Rights – Spanish

• Covered Employee Notification of Rights – English

• Employee Notification Affidavit – English/Spanish

• Instructions for Implementing the MPN – English

• Instructions for Implementing the MPN – Spanish

• MPN Implementation Notice to Employees

• Pre-designation of Personal Chiropractor or Personal Acupuncturist – English/Spanish

• Pre-designation of Personal Physician – English/Spanish

• Covered Employee Notification of Rights – Spanish

• Covered Employee Notification of Rights – English

• Employee Notification Affidavit – English/Spanish

• Instructions for Implementing the MPN – English

• Instructions for Implementing the MPN – Spanish

• MPN Implementation Notice to Employees

• Pre-designation of Personal Chiropractor or Personal Acupuncturist – English/Spanish

• Pre-designation of Personal Physician – English/Spanish

• Covered Employee Notification of Rights – Spanish

• Covered Employee Notification of Rights – English

• Employee Notification Affidavit – English/Spanish

• Instructions for Implementing the MPN – English

• Instructions for Implementing the MPN – Spanish

• MPN Implementation Notice to Employees

• Pre-designation of Personal Chiropractor or Personal Acupuncturist – English/Spanish

• Pre-designation of Personal Physician – English/Spanish

• Covered Employee Notification of Rights

• Employee Notification Affidavit – English/Spanish

• Instructions for Implementing the MPN – English

• Instructions for Implementing the MPN – Spanish

• MPN Implementation Notice to Employees

• Pre-designation of Personal Chiropractor or Personal Acupuncturist – English/Spanish

• Pre-designation of Personal Physician – English/Spanish

• Initial Written Employee Notification Re: Medical Provider Network

• Medical Provider Packet for Employers -English/Spanish

• Pre-designation of Personal Chiropractor or Personal Acupuncturist – English/Spanish

• Pre-designation of Personal Physician – English/Spanish

• Covered Employee Notification of Rights – Spanish

• Covered Employee Notification of Rights – English

• Employee Notification Affidavit – English/Spanish

• Instructions for Implementing the MPN – English

• Instructions for Implementing the MPN – Spanish

• MPN Implementation Notice to Employees

• Pre-designation of Personal Chiropractor or Personal Acupuncturist – English/Spanish

• Pre-designation of Personal Physician – English/Spanish

• Covered Employee Notification of Rights – Spanish

• Covered Employee Notification of Rights – English

• Employee Notification Affidavit – English/Spanish

• Instructions for Implementing the MPN – English

• Instructions for Implementing the MPN – Spanish

• MPN Implementation Notice to Employees

• Pre-designation of Personal Chiropractor or Personal Acupuncturist – English/Spanish

• Pre-designation of Personal Physician – English/Spanish

• Covered Employee Notification of Rights – Spanish

• Covered Employee Notification of Rights – English

• Employee Notification Affidavit – English/Spanish

• Instructions for Implementing the MPN – English

• Instructions for Implementing the MPN – Spanish

• MPN Implementation Notice to Employees

• Pre-designation of Personal Chiropractor or Personal Acupuncturist – English/Spanish

• Pre-designation of Personal Physician – English/Spanish

• Covered Employee Notification of Rights – Spanish

• Covered Employee Notification of Rights – English

• Employee Notification Affidavit – English/Spanish

• Instructions for Implementing the MPN – English

• Instructions for Implementing the MPN – Spanish

• MPN Implementation Notice to Employees

• Pre-designation of Personal Chiropractor or Personal Acupuncturist – English/Spanish

• Pre-designation of Personal Physician – English/Spanish

• Covered Employee Notification of Rights – Spanish

• Covered Employee Notification of Rights – English

• Employee Notification Affidavit – English/Spanish

• Instructions for Implementing the MPN – English

• Instructions for Implementing the MPN – Spanish

• MPN Implementation Notice to Employees

• Pre-designation of Personal Chiropractor or Personal Acupuncturist – English/Spanish

• Pre-designation of Personal Physician – English/Spanish

• Covered Employee Notification of Rights – Spanish

• Covered Employee Notification of Rights – English

• Employee Notification Affidavit – English/Spanish

• Instructions for Implementing the MPN – English

• Instructions for Implementing the MPN – Spanish

• MPN Implementation Notice to Employees

• Pre-designation of Personal Chiropractor or Personal Acupuncturist – English/Spanish

• Pre-designation of Personal Physician – English/Spanish

• Covered Employee Notification of Rights – Spanish

• Covered Employee Notification of Rights – English

• Employee Notification Affidavit – English/Spanish

• Instructions for Implementing the MPN – English

• Instructions for Implementing the MPN – Spanish

• MPN Implementation Notice to Employees

• Pre-designation of Personal Chiropractor or Personal Acupuncturist – English/Spanish

• Pre-designation of Personal Physician – English/Spanish

• Covered Employee Notification of Rights – Spanish

• Covered Employee Notification of Rights – English

• Employee Notification Affidavit – English/Spanish

• Instructions for Implementing the MPN – English

• Instructions for Implementing the MPN – Spanish

• MPN Implementation Notice to Employees

• Pre-designation of Personal Chiropractor or Personal Acupuncturist – English/Spanish

• Pre-designation of Personal Physician – English/Spanish