Form 42 Revised


TO: WCC Administrative Law Judges, District Administrators, Claimants, Self-Insureds, Insurance Carriers, Attorneys, Unions, and Advisory Board Members
FROM: Stephen M. Morelli, Chairperson
DATE: November 3, 2023
RE: Form 42 Revised


Form 42 has been revised to include a check box indicating "Check, if total impairment rating, inclusive of any prior ratings, for body part." The box should be checked when the rating is for the total impairment inclusive of any previous ratings for the body part. The box should not be checked when the rating is in addition to a previous rating. The revised form can be obtained from our Online Forms page.