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Division of Workers' Compensation

Notices

Form

Description

 

 

 

Final Payment Notice

Form #WC025

 

Fillable
MS Word

Whenever a worker’s compensation claim has been closed, the Insurer shall file a Final Payment Notice within 60 days of the date of closure. The information on this form captures the Insurer/TPA claim number, cost of claims for statistical reporting of trends, and for reports to the legislature.


Notice of Change of Carrier or Adjusting Firm
Form  #WC168

Fillable
MS Word

This form is used by the insurer or claims adjusting administrator to advise of any change in the claims administrator handling its workers' compensation claims.

 

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