Work comp: Forms
About the forms
The forms provided below are fillable PDFs that can be viewed or printed using the free Adobe Acrobat Reader software. However, that software does not allow users the option of saving data that is typed into the filled-in PDF; to have the option to save input information, visit www.adobe.com for more information about Adobe Acrobat software.
The fill-in PDF will automatically enter the slashes for dates, the parentheses and hyphen for phone numbers and the hyphens for Social Security numbers.
Work Comp Campus: Information about filing forms during Work Comp Campus transition
Online submission options
Attorney Request for Certification of Dispute, Medical Request, Medical Response, Rehabilitation Request, Rehabilitation Response
A feature of this online filing tool allows users to save filed dispute documents. It also requires users to login to the system in a new way – learn more. Because of the feature, users can now save incomplete files they are still working on, save completed files and review dispute documents that have already been filed.
– User information about submission of online Medical Request and Rehabilitation Request forms.
Mediation request available online from DLI's Alternative Dispute Resolution unit
A to Z – required workers' compensation forms (required by statute, rule)
The Spanish versions of forms are to be used for communication purposes only; they should not be filed with the department.
Workers' Compensation Report of Benefits Paid (updated annually)
Optional forms (suggested format, not required by statute, rule)
Rehabilitation provider forms
|Form name||Version date||Notes|
|R-20 Qualified Rehabilitation Consultant Intern Application||July 2015||Law change|
|R-22 Rehabilitation Vendor Application||July 2015||Law change|
|R-24 Qualified Rehabilitation Consultant Firm Application||July 2015||Law change|
|R-25 Qualified Rehabilitation Consultant Application||July 2015||Law change|