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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 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.

Learn about

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.

Form name Version date Notes
Affidavit of Significant Financial Hardship (AS01) June 2018 Legislative changes
Annual Claim for Reimbursement From the Second Injury Fund (AR04) September 2015 New fax number
Claim Petition for Dependency Benefits or Payment to Estate (CP03) June 2018 Legislative changes
Disability Status Report (DS01) October 2023 Removed address
Election to Exclude Relatives of Executive Officers of a Closely Held Corporation (SF0138) October 2025 Removed address
Election to Exclude Relatives of Managers of a Limited Liability Company (SF0137) October 2025 Removed address
Employee or Insurer's Objection to Requested Attorney Fees and/or Costs (RT01) June 2018 Legislative changes
Employee's Claim Petition (EC04) June 2018 Legislative changes
Employee's Objection to Discontinuance (ED02) June 2018 Legislative changes
Employee's Request for Administrative Conference (EQ05) – more information June 2018 Legislative changes
Excess Fee Exhibit (PF04) June 2018 Legislative changes

First Report of Injury (FR01) – more information

Amended rules effective for first reports of injury filed on or after Jan. 1, 2014:  5220.2530, 5220.2820, 5220.2830

 March 2016 New phone number
Health Care Provider Report (HC01) – more information April 2017 Format changes
Medical Request (MQ03) September 2023 Address update
Medical Response (MR03) September 2023 Address update
Notice of Benefit Reinstatement (NC01) – more information September 2015 Format changes
Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee (BD02) – more information October 2023 Removed address
Notice of Discontinuance of Workers' Compensation Dependency Benefits (DB02) – more information October 2023 Removed address
Notice of Insurer's Primary Liability Determination (NL01) – more information October 2023 Removed address
Notice of Intention to Discontinue Workers' Compensation Benefits (ND01) – more information October 2023 Removed address
Objection to Penalty Assessment (CE0003) May 2025 Updated mailing address, phone number
On-the-job Training Plan (JA04) October 2023 Removed address
Petition for Taxation of Actual and Necessary Disbursements (PT03) June 2018 Legislative changes
Plan Progress Report (PR01)
– Spanish version (informational, do not file)		 October 2023 Removed address
R-2 Rehabilitation Plan (RE01) – more information October 2023 Removed address
R-3 Rehabilitation Plan Amendment (RP01) – more information October 2023 Removed address
R-8 Notice of Rehabilitation Plan Closure (NR01) October 2023 Removed address

Rehabilitation Consultation Report (RC01)

– Spanish version (informational, do not file)

October 2023

May 2016

Removed address

Format changes
Rehabilitation Request (RQ03) September 2023 Address update
Rehabilitation Response (RR03) September 2023 Address update

Rehabilitation Rights and Responsibilities of the Injured Worker (IW05)

– Somali version (informational, do not file)
– Spanish version (informational, do not file)

October 2023

July 2025
May 2016

Removed address

First time translated
First time translated
Report of Work Ability (RW01) – more information May 2017 Format changes
Request for Extension (QE03) – more information July 2010  
Request for Formal Hearing (RF03) June 2018 Legislative changes
Retraining Plan (EP04) October 2023 Removed address
Statement of Attorney Fees and Costs (SA04) June 2018 Legislative changes

Miscellaneous form

Optional forms (suggested format, not required by statute, rule)

Form name Version date Notes
Authorization for File Review or Release of Copies of Workers' Compensation Claim File (FE0005) May 2025 Updated form
Benefit Addendum (BA01) – more information July 2010  
Disclosure of Affiliations and/or Relationships    
Model patient/provider contract for long-term treatment with opioid medication May 2016  
Motion to Intervene (MO0001) August 2018 Format changes
Notice of File Closing (NF01) – more information October 2023 Removed address
Notice of Penalty Payment (NO0015) October 2014 Format changes
Penalty Request -- Workers' Compensation October 2024 New form
Penalty Request for Failure to Pay or Deny Rehabilitation Invoice September 2024 Legislative changes

Rehabilitation provider forms

Form name Version date Notes
R-22 Rehabilitation Vendor Application October 2023 Removed phone number

More information