In observance of Thanksgiving, WCC offices will be closed on Thursday, November 24, 2022.

Insurance Forms

 

link opens in new browser tab  Form 36

PDF File:  1 page; Last revised October 1, 2021
 

Notice of Intention to Reduce or Discontinue Payments

The Form 36 is to be completed by the respondent (employer/workers’ compensation insurance carrier) to notify the Workers’ Compensation Commissioner, the claimant (employee/decedent), and all parties to the claim of its intention to reduce or discontinue payment of the claimant’s workers’ compensation benefits.

 


 

link opens in new browser tab  Form 44

PDF File:  1 page; Last revised July 13, 2009
 

Order to Second Injury Fund in Cases of Concurrent Employment

The Form 44 is to be completed by a workers’ compensation insurance carrier seeking reimbursement from the state Second Injury Fund. Once both the carrier and the Fund agree on the figures and sign the form, it is sent to the Commission for approval.

[NOTE: Read Memorandum No. 2004-04 for complete instructions regarding the filing of this form.]

 


 

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