Workers’ Compensation Forms

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01. WORKERS’ COMPENSATION FORM

C-3

  • Please answer all questions to best of your knowledge
  • If you do not know an answer, leave it blank
  • Call us if any trouble filling out the form
  • If you answered ‘Yes’ to question 5 on page 2 – you have prior injuries to the same body part, then please fill out and sign page 3

Sign on the bottom of page 2 where it says ‘employee’s signature’

  • Signature can be physical or electronic signature
  • If unable to sign, contact us
01. WORKERS’ COMPENSATION FORM
Workers Comp C3 EnglishDownload
02. WORKERS’ COMPENSATION FORM

OC-400 (Retainer)

  • Fill out just top parts – put in your WCB number if you have one, social security number and date of accident
  • Next to claimant please print your name and address
  • Next to employer please print the name and address
  • If you know the insurance carrier, please print name and address. Otherwise leave blank

Sign next to where it says ‘claimant’s signature’

  • Signature can be physical or electronic signature
  • If unable to sign, contact us
02. WORKERS’ COMPENSATION FORM
Workers Comp Retainer EnglishDownload
03. WORKERS’ COMPENSATION FORM

HIPPA

  • Fill out the information in the boxes at top
  • Print your name where else asked
  • Leave health provider’s name blank

Sign at the bottom

  • Signature can be physical or electronic
03. WORKERS’ COMPENSATION FORM
Workers Comp HIPAA EnglishDownload
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