Division of Workers' Compensation

Admissions and Denials

Form	Description
General Admission of Liability Form #WC2 Fillable MS Word	This form is used by the insurer to voluntarily admit responsibility for payment of workers’ compensation benefits. It is an important legal document that provides an initial statement of the amount of benefits to be paid in a workers’ compensation case.
Final Admission of Liability Form #WC4 Fillable MS Word	This form is the final statement by the insurer of the amount of benefits to be paid in a workers’ compensation case. If there is no objection to the final admission by the claimant within the prescribed time frame, the admission becomes final and the claim is closed.
Fatal General Admission Form #WC 151 Fillable MS Word	This form is used by the insurer to voluntarily admit responsibility for payment of workers’ compensation benefits where a fatality has occurred. It is an important legal document that provides an initial statement of the amount of benefits to be paid in a workers’ compensation case.
Fatal Final Admission Form #WC 153 Fillable MS Word	This form is the final statement by the insurer of the amount of benefits to be paid in a workers’ compensation case where a fatality has occurred. If there is no objection to the final admission by the claimant within the prescribed time frame, the admission becomes final and the claim is closed.
Notice of Contest Form #WC74 Fillable MS Word	This form is used by the insurer to deny liability responsibility for workers’ compensation benefits.
Petition to Modify, Terminate, or Suspend Compensation Form #WC54 Fillable MS Word	This form is used by an insurer to request that the Director modify, terminate, or suspend a claimant’s temporary disability benefits based on facts that are outlined in the petition.
Objection to Petition to Modify, Terminate, or Suspend Compensation Form #WC55 Fillable MS Word	This form is used by the claimant to object to a Petition to Modify, Terminate or Suspend Compensation. This form is required to be filed with WC54 - Petition to Modify.