Claims Kit

When it comes to the complexities of workers’ compensation, you can rely on our deep expertise to help you navigate specific state regulations and claims forms. These resources provide the valuable information and tools you need when dealing with a workplace injury.

For help identifying your insurance company, please contact us at 800.231.1363.

Insurance Company*

Resource*

State*

Your Claims Kit will include:

State Forms
Posters & Brochures
State Compliance Information
Injured Worker Resources
Documents Provided by CopperPoint, Alaska National and PacificComp

Washington, D.C.

Claims Kit Contents

Claims Handled By
PacificComp Insurance Company
P.O. Box 5042
Thousand Oaks, CA 91359-5042

Agreement Between Employer / Employee Choice of Physician

Agreement Between Employer / Employee Choice of Physician (Spanish)

Alternative Choice of Physician or Chiropractor

Application for 104 Weeks Dependents' Benefits

Application for Fatal Dependents' Benefits

Authorization and Request for Unemployment

Average Weekly Wage Certification

Average Weekly Wage Certification-Concurrent

Average Weekly Wage Certification-Post Injury

Average Weekly Wage Computation Schedule

Average Weekly Wage Worksheet

Choice of Doctor

Choice of Doctor (Spanish)

Claimant's First Notice of Death and Claim for Compensation

Direct Deposit and Debit Card Authorization Form

Direct Deposit and Debit Card Authorization Form - Sample Version ONLY

Employee Report of Occupational Injury or Illness to Employer

Employee's Claim for Compensation / Report of Initial Treatment

Employee's First Notice of Accidental Injury and Claim for Compensation.

Employee's First Notice of Occupational Disease and Claim for Compensation

Employee's Notice of Accidental Injury or Occupational Disease

Employee's Notice of Rejection of Terms of the Arizona Workers' Compensation Law

Employee's Wage Report

Employees Claim and Employer First Report of Injury

Employees Notice of Injury and Claim for Compensation

Employees' and Physicians' Report of Occupational Hearing Loss

Employees' and Physicians' Report of Occupational Injury or Disease

Employees' Report of Occupational Pneumoconiosis

Employer First Report of Injury / Fatality

Employer First Report of Injury or Disease

Employer Report of Employee Earnings - formerly Wage Statement (C-94A)

Employer Report of Employee Earnings - formerly Wage Statement (C-94A) (Spanish)

Employer Report of Occupational Injury or Illness to Division of Workers' Compensation

Employer's First Report of Alleged Occupational Injury or Disease

Employer's First Report of Injury

Employer's First Report of Injury Must be submitted electronically.

Employer's First Report of Injury or Illness

Employer's First Report of Injury or Occupational Disease

Employer's First Report of Injury or Occupational Disease.

Employer's First Report of Occupational Injury or Disease

Employer's First Report of Occupational Injury or Disease Form

Employer's First Report of Occupational Injury or Illness

Employer's Modified Duty Availability Report

Employer's Multiple Employment Wage Statement

Employer's Multiple Employment Wage Statement (Spanish)

Employer's Notice of No Coverage or Termination of Coverage

Employer's Notice of No Coverage or Termination of Coverage (Spanish)

Employer's Report for Reimbursement of Voluntary Payment

Employer's Report of Employee's Injury or Occupational Disease to the Industrial Commission

Employer's Report of Industrial Injury

Employer's Report of Industrial Injury or Occupational Disease

Employer's Report of Injured Employee's Change in Employment Status Resulting From Injury Required

Employer's Report of Injury

Employer's Report of Non-covered Employee's Occupational Injury or Disease

Employer's Report of Occupational Injury or Illness Required

Employer's Report of Work-Related Injury/Illness

Employer's Report of Work-Related Injury/Illness (Spanish)

Employer's Statement of Wage Earnings (C-240) (Preceding The Date of Injury/Illness)

Employer's Supplemental Report

Employer's Supplemental Report of Injury

Employer's Wage Statement

Employer's Wage Statement (Spanish)

Employer's Wage Statement for School Districts

Employer's Wage Statement for School Districts (Spanish)

Employer's Wage Verification Form

Employers First Report of Injury or Illness

Employers Report of Accident

Employers' First Notice of Injury

Employers' Report of Occupational Injury or Disease

Fatality Report Required

First Report Instructions

First Report of Alleged Occupational Injury or Illness

First Report of an Injury, Occupational Disease or Death

First Report of an Injury, Occupational Disease or Death (Spanish)

First Report of Injury

First Report of Injury (FR01)

First Report of Injury (FROI)

First Report of Injury - Employer's form

First Report of Injury and Occupational Disease (FROI)

First Report of Injury Instructions

First Report of Injury or Illness

First Report of Occupational Fatality Missouri Census of Fatal Occupational Injuries

First Report of Occupational Injury or Disease

First Report of Work Injury ( C-20 )

Fraud & Compliance Unit Claim Referral/Initial Information Report Required

General Admission of Liability

Glossary of Workers' Compensation Terms for Injured Workers

Governmental Entities Agreement Between Employer / Employee Choice of Physician Form

Initial Statement of Insurance Carrier / Self Insurer with Respect to Payment of Benefits

Injured Workers' Rights and Responsibilities

Insurance Company Fraud Contact Form

Medical Treatment for Your Work Injury or Occupational Illness

Medical Waiver and Consent

Mileage Reimbursement Form

Notice of Accident or Occupational Disease Disablement (English and Spanish)

Notice of Accident to Employer and Claim of Employee, Representative, or Dependent

Notice of Accident to Employer and Claim of Employee, Representative, or Dependent (Spanish)

Notice of Accidental Injury or Occupational Disease

Notice of Designated Physician

Notice of Employee Death Required

Notice of Injury or Occupational Disease (Incident Report)

Notice of Personal Chiropractor or Personal Acupuncturist

Notice of Personal Chiropractor or Personal Acupuncturist (Spanish)

OCR-Employer's Basic Report of Injury

Plaintiff's Chronological Medical History

Predesignation of Personal Physician

Predesignation of Personal Physician (Spanish)

Program Review Report

Release of Medical and Other Information For Nevada Workersâ€™ Compensation Claims

Release of Medical and Other Information For Nevada Workers’ Compensation Claims

Release of Medical and Other Information For Nevada Workers’ Compensation Claims - Effective 9/13/2023 Discontinued from use

Report of Fatal Accident

Report of Injury

Report of Injury or Illness Required

Report of Injury or Illness (Spanish) Required

Request for a Rotating Rating Physician or Chiropractor

Request for Extension of Time

Request for Social Security Disability Benefit Information

Schedule of Dependent(s) and Filing Status Statement

Statement of Days Worked and Earnings of Injured Employee

Statement of Earnings of Injured Employee

Statement of Wage Information

Statement of Wage Information- ** Please Note, NO Calculations version**

Statement of Wages

Statement of Weekly Earnings

Subsequent Report

Subsequent Report of Injury (SROI)

Supplemental Report

Supplemental Report of Fatal Injury

Supplemental Report of Injury Required

Supplemental Report of Return to Work

Supplemental Wage Schedule - MS Excel Document Download

Suspected Insurance Fraud Citizen Reporting Form

Uniform Suspected Insurance Fraud Reporting

Utilization Review Complaint Form

Wage Calculation Form for Claims Agent's Use

Wage Chart

Wage Information Supplement

Wage Informational Supplement

Wage Schedule

Wage Statement

Wage Statement: Full Time

Wage Statement: Part Time

Wage Statement: Seasonal

Workers' and Physician's Report of Injury

Workers' Compensation - First Report of Injury or Illness

Workers' Compensation Claim form (Employee) Required

Workers' Compensation Claim form (Employee) - Bilingual Required

Posters and Brochures

NOTICE - Important Information for Injured Employees (Spanish) Required

NOTICE - Important Information for Injured Employees - (Spanish) Required

OFFICIAL NOTICE Panel of Physicians Required

"A Guide for Workers" Recently Hurt on the Job" Required

"A Guide for Workers" Recently Hurt on the Job"(Spanish) Required

Posters are only required for certain agricultural operations. If you are agricultural check "Posting Requirements" under the "Compliance Information".

A Beginners Guide to Tennessee Workers Compensation Claims (Spanish)

A Guide For Workers Recently Hurt On The Job Required

A Guide for Workers Recently Hurt on the Job - Spanish Required

A Guide to Workers

A Guide to Workers Compensation For Wyoming Claimants

A Guide to Workers Compensation For Wyoming Employers

A Guide to Workers" Compensation in Wyoming

Already Have a Poster? Fill out this Label

Answers to Your Questions about Permanent Disability Benefits

Answers to Your Questions about Permanent Disability Benefits (Spanish)

Answers to Your Questions about Qualified Medical Evaluators and Agreed Medical Evaluators

Answers to Your Questions about Qualified Medical Evaluators and Agreed Medical Evaluators (Spanish)

Answers to Your Questions about Temporary Disability Benefits

Answers to Your Questions about Temporary Disability Benefits (Spanish)

Answers to Your Questions about the State's Uninsured Employers Benefits Trust Fund

Answers to Your Questions about the State's Uninsured Employers Benefits Trust Fund (Spanish)

Answers to Your Questions about Utilization Review

Answers to Your Questions about Utilization Review (Spanish)

BROCHURE - Workers Required

BROCHURE - Workers" Compensation Information for Kansas Employers and Employees (Spanish) Required

BROCHURE - Workers" Compensation Information for Kansas Employers and Employees (Spanish)

BROCHURE - Injured Workers

BROCHURE - Injured Workers" Guide (Spanish)

BROCHURE - Rights and Benefits for Workers" Injured on the Job

BROCHURE - Workers' Compensation Guidebook

BROCHURE - A Beginner's Guide to Workers' Compensation Required

BROCHURE - A Guidebook for Employers in New Mexico

BROCHURE - A Guidebook for Employers in New Mexico (Spanish)

BROCHURE - An Employee's Guide to the Minnesota Workers' Compensation System Required

BROCHURE - An Employee's Guide to the Minnesota Workers' Compensation System (Spanish) Required

BROCHURE - An Employee's Guide to the South Dakota Workers' Compensation System

BROCHURE - An Employer's Guide to a Drug-Free Workplace

BROCHURE - Arkansas Workers' Compensation Questions & Answers

BROCHURE - Best Practices for Communication with Workers" Compensation System

BROCHURE - Best Practices for Early Return to Work

BROCHURE - Best Practices for Proper Claim Reporting

BROCHURE - Best Practices for Role of the Employer

BROCHURE - Best Practices for Selecting Physicians for Your Panel

BROCHURE - Drug Free Way to Be

BROCHURE - Employee's Guide

BROCHURE - Employee's Guide (Spanish)

BROCHURE - Employee's Rights and Obligations Information Sheet Required

BROCHURE - Employer's Guide

BROCHURE - Employer's Guide to Reporting an Employee Injury

BROCHURE - Employers Frequently Asked Questions

BROCHURE - Facts about Workers' Compensation (Time of Hire Pamphlet from CA DWC) Required

BROCHURE - Facts about Workers' Compensation(Time of Hire Pamphlet from CA DWC) (Spanish)

BROCHURE - Facts for Employers

BROCHURE - Facts for Injured Workers

BROCHURE - Facts for Injured Workers (Spanish)

BROCHURE - Highlights of the Hawaii Workers' Compensation Law Required

BROCHURE - Important Workers' Compensation Information for Florida Employers Required

BROCHURE - Important Workers' Compensation Information for Florida Employers (Spanish) Required

BROCHURE - Important Workers' Compensation Information for Florida Workers Required

BROCHURE - Important Workers' Compensation Information for Florida Workers (Spanish) Required

BROCHURE - Important Workers' Compensation Information for Florida Workers" (Spanish) Required

BROCHURE - Injured on the Job, an Employee's Guide to Workers' Compensation in New York State Required

BROCHURE - Injured on the Job, an Employee's Guide to Workers' Compensation in New York State (Spanish) Required

BROCHURE - Injured Worker's Guide to Reporting an Injury

BROCHURE - Minnesota Workers' Compensation System Employee Information Sheet Required

BROCHURE - Minnesota Workers' Compensation System Employee Information Sheet (Spanish) Required

BROCHURE - Notice to Employees - Tip Information

BROCHURE - Notice to Employer Regarding Obligations Under Virginia WC Act

BROCHURE - Q & A for Employees about Maryland Workers' Compensation Law

BROCHURE - Q & A for Employers about Maryland Workers' Compensation Law

BROCHURE - Questions and Answers about Workers' Compensation Law for Injured Workers - Effective July 1, 2017 - June 30, 2018

BROCHURE - Questions and Answers about Workers' Compensation Law for Injured Workers - Effective July 1, 2018 - June 30, 2019

BROCHURE - Questions and Answers about Workers' Compensation Law for Injured Workers - Effective July 1, 2019 - June 30, 2020

BROCHURE - Questions and Answers about Workers' Compensation Law for Injured Workers - Effective July 1, 2020 - June 30, 2021

BROCHURE - Questions and Answers about Workers' Compensation Law for Injured Workers Effective July 1, 2016 - June 30, 2017

BROCHURE - Questions and Answers about Workers' Compensation Law for Injured Workers Effective July 1, 2021 - June 30, 2022

BROCHURE - Questions and Answers about Workers' Compensation Law for Injured Workers" - Effective July 1, 2014 - June 30, 2015

BROCHURE - Questions and Answers about Workers' Compensation Law for Injured Workers" - Effective July 1, 2015 - June 30, 2016

BROCHURE - Rehabilitation Services for Injured Workers

BROCHURE - Rights & Obligations under the Nebraska Workers' Compensation Law

BROCHURE - Rights & Obligations under the Nebraska Workers' Compensation Law (Spanish)

BROCHURE - Stop Fraud

BROCHURE - Understanding Workers' Compensation

BROCHURE - Understanding Workers' Compensation (Spanish)

BROCHURE - Vocational Rehabilitation Services under the Nebraska Workers' Compensation Law (Spanish)

BROCHURE - Vocational Rehabilitation Services under the Nebraska Workers' Compensation Law

BROCHURE - Vocational Rehabilitation Servicesunder the Nebraska Workers'Compensation Law (Spanish)

BROCHURE - What happens if I'm hurt on the job? (English) Required

BROCHURE - What happens if I'm hurt on the job? (Spanish)

BROCHURE - Workbook for Injured Workers

BROCHURE - Workbook for Injured Workers ( English )

BROCHURE - Workbook for Injured Workers ( Spanish )

BROCHURE - Worker's Compensation Fraud

BROCHURE - Workers

BROCHURE - Workers Compensation Information for Kansas Employers and Employees

BROCHURE - Workers" Compensation Information for Kansas Employers and Employees

BROCHURE - Workers' Compensation and You - Information for Injured Workers

BROCHURE - Workers' Compensation and You: A Guide for Injured Workers

BROCHURE - Workers' Compensation Information for the Injured Worker

BROCHURE - Workers' Compensation Information Packet

BROCHURE - Workers' Compensation Information Packet (Spanish)

BROCHURE -Brief Description of Your Rights and Benefits if You Are Injured on the Job Required

Brochure -Handbook on Workers' Compensation and Occupational Diseases for Injuries and Illnesses Required

Brochure -Handbook on Workers' Compensation and Occupational Diseases for Injuries and Illnesses (Spanish) Required

BROCHURE- - Quick Reference Guide for Workers

Brochure- Division of Workers Compensation Fact Sheet

BROCHURE- Questions and Answers about Workers Compensation Law for Injured Workers Effective July 1, 2022 - June 30, 2023

BROCHURE- Questions and Answers about Workers Compensation Law for Injured Workers Effective July 1, 2023 - June 30, 2024

BROCHURE-Putting Together a Safe Workplace

California SB 1159 Covid 19 Required Reporting Documentation Required

Claimant Brochure: Know Your Rights as an Injured Worker Required

Claimant Brochure: Know Your Rights as an Injured Worker (Spanish) Required

Claimant Brochure: Know Your Rights as an Injured Worker- Spanish Required

Early Return-to-Work Initiative- Flyer

Employee Notification Letter

Employee Notification Letter (Spanish)

Employee Rights and Duties form Required

Employer Frequently Asked Questions

Employer Guide 2020

Employer Guide 2020 (Spanish)

Employer Guide 2020 - Spanish

EMPLOYERS: What Should I expect from my insurer?

For Employers who do not have coverage

Fraud Prevention Tips For Employers

Glossary of Workers' Compensation Terms for Injured Workers (Spanish)

Guide To Workers Compensation Law in South Dakota

Injured Employee Rights and Responsibilities

Injured Employee Rights and Responsibilities (Spanish)

Injured Worker Guide 2020

Injured Worker Guide 2020 - Spanish

Injured Worker Guide 2021

Injured Worker Guide 2021 (Spanish)

Injured Worker Guide 2021 - Spanish

New Employee Notice (covered and non-covered employers shall notify their employees of coverage status, in writing,

New Employee Notice - (Spanish)

Notice - Employee Notice Ombudsman Program Required

Notice - Employee Notice Ombudsman Program (Spanish) Required

Notice - Employer's Notice of First Responder Liaison to Employees Required

Notice - Employer's Notice of First Responder Liaison to Employees (Spanish) Required

NOTICE - Important Information for Injured Employees Required

NOTICE - Workers" Compensation Filing Information Required

NOTICE -Information Regarding Workers' Compensation and a Claimant's Rights

NOTICE OF COMPLIANCE - Ordering information.

Notice of Compliance Information

Notice of Employer Rights and Responsibilities in a Workersâ€™ Compensation Claim

Notice of Employer Rights and Responsibilities in a Workers’ Compensation Claim Required

Notice of Injured Employee Rights and Responsibilities in the Texas Workers' Compensation System Required

Notice of Injured Employee Rights and Responsibilities in the Texas Workers' Compensation System (Spanish) Required

Notice of Reported Injury Required

Notice to Employees Concerning Workers' Compensation in Texas Required

Notice to Employees Concerning Workers' Compensation in Texas - (Spanish) Required

Notice to Employer/Notice to Employee

Notice to Employer/Notice to Employee (Spanish)

OFFICIAL NOTICE Panel of Physicians - (Spanish) Required

OFFICIAL NOTICE WC/MCO Panel Required

OFFICIAL NOTICE WC/MCO Panel - (Spanish) Required

OWC Employers Brochure

OWC Employers Brochure (Spanish Version)

OWC Employers Brochure-Spanish Version

OWC Workers Brochure

OWC Workers Brochure (Spanish)

OWC Workers Brochure- Spanish

POSTER - Notice of Coverage (Spanish) Required

POSTER - Employer Notice of Workers' Compensation Insurance Coverage- (English & Spanish) Required

POSTER - Employer's Compliance with Workers' Compensation Law (English and Spanish) Required

POSTER - Notice To Employees Poster (Spanish) Required

POSTER - Workers' Compensation Notice of Compliance - Employer Form Required

POSTER - Workers' Compensation Notice of Compliance - Employer Form (Spanish) Required

POSTER - Anti-Fraud Poster Required

POSTER - Anti-Fraud Poster (Spanish)

POSTER - Bill of Rights Required

POSTER - Bill of Rights - (Spanish) Required

POSTER - Broken Arm Poster - 11 x 17 Size (Spanish)

POSTER - Broken Arm Poster - 11 x 17 Size

POSTER - Criteria to Establish an Employee or Independent Contractor Required

POSTER - Drug Free Workplace Required

POSTER - DWC- 7 Notice to Employees Poster - (English and Spanish) Required

Poster - Employee Warning -Termination of Coverage

POSTER - Employees - Know Your Rights! Required

POSTER - Employers' Notice of Insurance Required

POSTER - Fraud Poster Required

POSTER - Generic Notice to Employees poster.

POSTER - Health Notice for Managed Care

POSTER - Informational Poster Required

POSTER - Job Safety and Health Required

POSTER - Job Safety and Health Law Required

POSTER - Labor Law Required

POSTER - Labor Law (Spanish) Required

POSTER - Labor Law Posters (Complete set) Required

POSTER - N.C. Workers' Compensation Notice to Injured Workers and Employers Required

POSTER - N.C. Workers' Compensation Notice to Injured Workers and Employers (Spanish) Required

POSTER - Notice for Employees Poster Required

POSTER - Notice of Coverage Required

POSTER - Notice Regarding Workers' Compensation Required

POSTER - Notice Regarding Workers' Compensation (Spanish) Required

POSTER - Notice Regarding Workers' Compensation - (Spanish) Required

POSTER - Notice to Employee - Coal Miners Required

POSTER - Notice to Employees Required

POSTER - Notice To Employees Poster Required

POSTER - Notice to Employer of Injury (11 x 14) Required

POSTER - Noticia Sobre Compensacion Laboral Required

POSTER - Oklahoma Workers' Compensation Notice and Instruction to Employers and Employees Required

POSTER - Oklahoma Workers' Compensation Notice and Instruction to Employers and Employees (Spanish) Required

POSTER - Poster of Instructions Required

POSTER - Poster of Instructions (Spanish) Required

POSTER - Posting Notice Required

POSTER - Remember: It Is Important To Tell Your Employer About Your Injury Required

POSTER - Remember: It Is Important To Tell Your Employer About Your Injury (Spanish) Required

POSTER - Remember: It Is Important To Tell Your Employer About Your Injury- Spanish Required

POSTER - Rights and Responsibilities

POSTER - Safety and health protection on the job Required

POSTER - Safety on the Job Poster Required

POSTER - Safety on the Job Poster (Spanish) Required

POSTER - Self-Insurance Poster (English and Spanish) Required

POSTER - Stop Workers" Compensation Fraud Poster Required

POSTER - Stop Workers" Compensation Fraud Poster (Spanish) Required

POSTER - Tennessee Workers' Compensation Insurance Posting Notice Required

POSTER - Tennessee Workers' Compensation Insurance Posting Notice (Spanish) Required

POSTER - WC Act Summary Required

POSTER - WC Act Summary Spanish) Required

POSTER - Work Exposure to Bodily Fluids (English and Spanish) Required

POSTER - Work Exposure to Methicillin-Resistant Staphylococcus aureus (MRSA), Spinal Meningitis, or Tuberculosis (TB) Required

POSTER - Work Place Safety (English and Spanish) Required

POSTER - Worker's Compensation Notice Required

POSTER - Worker's Compensation Notice (Spanish) Required

POSTER - Workers

POSTER - Workers' Compensation Poster (Spanish) Required

POSTER - Workers' Compensation Required

POSTER - Workers' Compensation (Spanish) Required

POSTER - Workers' Compensation - (Spanish) Required

POSTER - Workers' Compensation Board Notice to Employees Required

POSTER - Workers' Compensation Notice Required

POSTER - Workers' Compensation Notice (Spanish) Required

POSTER - Workers' Compensation Notice - (Spanish) Required

POSTER - Workers' Compensation Poster Required

POSTER - Workers' Compensation Poster

POSTER - Workers' Compensation Poster Required

POSTER - Workers' Compensation Poster (Spanish) Required

POSTER - Workers' Compensation Poster - (Spanish) Required

POSTER - Workplace Notice Required

POSTER - Workplace Notice (Spanish) Required

POSTER - Wyoming Workers' Compensation Act Required

POSTER - Your Rights as a Worker in Washington State Required

POSTER - Your Rights as a Worker in Washington State - (Spanish) Required

POSTER - Your Rights as a Worker in Washington State-Spanish Required

POSTER -Employers Liability and Workers" Compensation Poster- (Form 31) - (Spanish) Required

POSTER -Employers Liability and Workers" Compensation Poster (Form 31) Required

Poster Employee Notice

Poster Employee Notice (Spanish)

Poster Employee Warning - Pending Cancellation of Coverage

Poster Regulations Required

POSTER- WC-9 Employers Reinstatement Liability Poster Required

POSTER-Notice To Employer of Injury Poster (Must be printed as 27 x 40 on single sheet or multiple sheets taped together) Required

POSTER-Notice To Employer of Injury Poster -27 x 40 Required Size Effective 8/10/22 Required

Preferred Provider Program advisory notice

Preferred Provider Program Advisory Notice - (Spanish)

Preferred Provider Program notice - (Spanish)

Preferred Provider Program notice.

Report of Fraud or Abuse (Confidential)

Report of Suspected Workers

Safety and health protection on the job

Safety and health protection on the job (Spanish)

SIU Stop Fraud

Statement of Rights ( WCL) - (Spanish) Required

Statement of Rights (WCL) Required

Third Party Election Form / Brochure- Injured by a Third Party?

Utah Occupational Safety and Health Poster Required

Utah Occupational Safety and Health Poster (Spanish) Required

Utah Occupational Safety and Health Poster - (Spanish) Required

WCA - POSTER - 11 x 17 version Required

WCA - POSTER - 8-1/2 x 11 Two-part Version Required

WCA - POSTER - Fraud Poster Required

Workers Compensation Brochure

Workers Compensation Multilingual Help Page Required

Workers have a right to file for workers compensation for COVID-19

Workers have a right to file for workers compensation for COVID-19 (Spanish)

Workers have a right to file for workers compensation for COVID-19-Spanish

Workers" Compensation Information form Required

Workers" Compensation Election Information

Workers' Compensation Fraud Inspector General Complaint Form

Workers' Compensation: Fraud and Noncompliance (Brochure)

You Were Injured On The Job, What Now ? Required

You Were Injured On The Job, What Now ? (Spanish) Required

Penalties for Late Reporting

Physician Selection

Posting Requirements

Reporting of Claim by Employer

Reporting of claim by Employer

Reporting of Claim by Employer

Reporting of claim by Employer

Reporting of Claim by Employer

Documents Provided by CopperPoint

After you complete the Employerâ€™s Report of Injury form, located in the forms section above, please submit the form via your CopperPoint portal or email it to reportaclaim@copperpoint.com. CopperPoint will forward a copy of your report to the Industrial Commission of Arizona (ICA) on your behalf.

Portal User Guides
Pharmacy First Fill
Worker's Report of Injury and Release of Medical Authorization
(to view and download, right mouse click on the link, select "save link as")
Medical Authorization Form
Wage Form
Travel Reimbursement - English
Travel Reimbursement - Spanish
Change of Address
Witness Statement
Accident Report - English
Accident Report - Spanish
Gramm-Leach-Bliley Act (GLBA) Privacy Notice - English

Return To Work

Return To Work Transitional Employment Offer Template
Return To Work Policy Guide

Injured Worker Resources

2024 Mailing Schedule for Permanent Benefit Checks

Medical Provider Required Information

Documents Provided by Alaska National

Return To Work

Return To Work Transitional Employment Offer Template
Return To Work Policy Guide

Documents Provided by Alaska National

Return To Work

Return To Work Transitional Employment Offer Template
Return To Work Policy Guide

Documents Provided by Alaska National

Return To Work

Documents Provided by Alaska National

Arizona | Injured Worker Guide

The workerâ€™s compensation system can be complicated, and each state has its own laws regarding workersâ€™ compensation.

The information contained in your stateâ€™s guide provides a general guide for workers injured or made ill on the job.

DWC Fact Sheets are documents that can be used by both the injured workers and the Policyholders to provide an overview of the laws that govern the claims administration process in the State of California. These forms are also available on the DWC website at www.dir.ca.gov

Employee Fact Sheets

Fact Sheet A: Utilization Review Fact Sheet â€“ English | Spanish
Fact Sheet B: Glossary of Workersâ€™ Comp Terms â€“ English | Spanish
Fact Sheet C: Temporary Disability Fact Sheet â€“ English | Spanish
Fact Sheet D: Permanent Disability Fact Sheet â€“ English | Spanish
Fact Sheet E: Qualified Medical Evaluation/Agreed Medical Evaluation Fact Sheet â€“ English | Spanish

Medical Records Release of Injured Worker

When injured workers sign this form, they give CopperPoint permission to obtain their medical records so that CopperPoint can evaluate their claim.

English and Spanish

Mileage Reimbursement Request for Injured Worker Use

Publications

Injured Workers' Guide

Indiana | Injured Worker Guide

Publications

Injured Workers' Guide

Montana | Injured Worker Guide

Injured Workers' Brochure - Spanish

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Claims Kit

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Alaska

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Arkansas

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California

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Connenticut

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Delaware

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Florida

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Georgia

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Hawaii

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Idaho

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Illinois

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Indiana

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Iowa

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Kansas

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Kentucky

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Louisiana

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Maine

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Massachusetts

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Maryland

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Michigan

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Minnesota

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Mississippi

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Missouri

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Montana

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Nebraska

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New Hampshire

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New Jersey

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New York

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North Carolina