Workers' Compensation Forms

Claim Form (DWC-1)

If you are injured on the job, your employer should give you a claim form. If they haven't provided you a claim form, and you were injured on the job, then you can download the form here and fill out and mail it to your employer Certified Mail Return Receipt.

Note: We are providing this form for your convenience. We are not taking action on your claim unless we have met in person and have a mutual written agreement to represent you in your case.

Doctor Pre-Designation

This Doctor Pre-Designation Form was created by the Division of Workers' Compensation to allow an injured worker to predesignate a physician prior to an industrial injury. You can download it by clicking here. Once you fill out the form, make a copy for yourself, provide it to your employer, and note the date your provided it to them.

Medical Mileage Expenses

You are entitled to medical mileage, which includes transportation to and from the treating physician, physical therapy, and the pharmacy. Mileage forms are different depending on the year you incurred the mileage. For example, if you were injured in 2013 and you have mileage in 2013, 2014, and 2015 that you have never submitted and you desire to get paid on your back-mileage, then you would need to download a different form for each year.

Download | For travel on or after 01/01/2017
Download | For travel on or after 01/01/2016
Download | For travel on or after 01/01/2015
Download | For travel on or after 01/01/2014
Download | For travel on or after 01/01/2013
Download | For travel on or after 07/01/2011
Download | For travel on or after 01/01/2011
Download | For travel on or after 01/01/2010
Download | For travel on or after 01/01/2009
Download | For travel on or after 07/01/2008
Download | For travel on or after 01/01/2008
Download | For travel on or after 01/01/2007
Download | For travel between 07/01/2006 and 01/01/2007

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