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Workers' Compensation Forms



Claims Procedure Checklists

WC Policies & Procedure : Claims Procedure Checklist (PDF, 183 KB)

Authorization for Release of Information

SORM16_InfoRelease[2] : Inormation Release Form (PDF, 46 KB)

Employee's Report of Injury

SORM-29_EmployeesReportOfInjury[2] : Employee Report of Injury (PDF, 500 KB)

Request for Travel Reimbursement

dwc048_trvlreim (PDF, 168 KB)

Witness Statement

SORM74_WitnessStatement[2] : Witness Statement (PDF, 56 KB)

Employees Election Regarding Utilization of Sick and Annual Leave

SORM-80_SickAnnualleave[2] : Sick & Annual Leave Usage Election (PDF, 141 KB)

Medical Reimbursement Request Form

SORM-81A (PDF, 372 KB)

SORM/IMO Network Acknowledgement Form