1. No category

WORKERS’ COMPENSATION
Claims Kit
Dear Customer,
Thank you for choosing ProSight Specialty Insurance as your Workers’ Compensation
Insurance carrier. We pride ourselves on providing excellent service and will do our
very best to meet your Workers Compensation Claims needs.
ProSight Specialty Insurance writes our Workers’ Compensation policies through our
New York Marine and General Insurance Company underwriting company, which is
the name you will see listed on your policy.
ProSight has partnered with a leading Workers’ Compensation claims service provider,
LWP Claims Solutions, for our policyholders who do business exclusively in California.
LWP will assist us in the administration of claims and will be the primary point of contact
for your claims.
Please make sure to include your Policy Number on all correspondence.
For your convenience, the following documents can be found inside your claims kit:
•
•
•
•
•
•
•
Instructions on how to report a claim
Claim Handling Map
List of Claim office locations, mailing addresses, and claim contacts
How to locate a Physician/Facility in California
Pharmacy cards
Links to your state’s Workers’ Compensation forms and Web Pages
Blank forms to use when reporting a claim (California only)
Please do not hesitate to contact us should you have any questions or concerns.
Workers’ Compensation Claims Department
ProSight Specialty Insurance
412 Mt. Kemble Avenue
Morristown, NJ 07960
[email protected]
Phone: 800-774-2755
Fax: 855-657-3534
California State Reporting Forms
Reporting Forms for all other states can be obtained
by accessing your state’s Workers’ Compensation
website (see previous page)
State of California
Please complete in triplicate (type if possible) Mail two copies to:
EMPLOYER'S REPORT OF
OCCUPATIONAL INJURY OR ILLNESS
OSHA CASE NO.
FATALITY
Any person who makes or causes to be made any
knowingly false or fraudulent material statement or
material representation for the purpose of obtaining or
denying workers compensation benefits or payments is
guilty of a felony.
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond the
date of the incident OR requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or
illness, the employer must file within five days of knowledge an amended report indicating death. In addition, every serious injury, illness, or death
must be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.
1. FIRM NAME
Ia. Policy Number
Please do not use
this column
2. MAILING ADDRESS: (Number, Street, City, Zip)
E
M
P
L 3. LOCATION if different from Mailing Address (Number, Street, City and Zip)
O
Y
E 4. NATURE OF BUSINESS; e.g.. Painting contractor, wholesale grocer, sawmill, hotel, etc.
R
6. TYPE OF EMPLOYER:
Private
County
State
7. DATE OF INJURY / ONSET OF ILLNESS 8. TIME INJURY/ILLNESS OCCURRED
(mm/dd/yy)
CASE NUMBER
3a. Location Code
OWNERSHIP
5. State unemployment insurance acct.no
City
School District
AM
INDUSTRY
Other Gov't, Specify:
10. IF EMPLOYEE DIED, DATE OF DEATH (mm/dd/yy)
9. TIME EMPLOYEE BEGAN WORK
PM
AM
1 1. UNABLE TO WORK FOR AT LEAST ONE 12. DATE LAST WORKED (mm/dd/yy)
FULL DAY AFTER DATE OF INJURY?
Yes
2a. Phone Number
OCCUPATION
PM
13. DATE RETURNED TO WORK (mm/dd/yy)
14. IF STILL OFF WORK, CHECK THIS BOX:
No
15. PAID FULL DAYS WAGES FOR DATE OF 16. SALARY BEING CONTINUED?
NJURY OR LAST
Yes
No
DAY WORKED?
Yes
No
17. DATE OF EMPLOYER'S KNOWLEDGE /NOTICE OF 18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM
FORM (mm/dd/yy)
INJURY/ILLNESS (mm/dd/yy)
SEX
19. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS if available, e.g.. Second degree burns on right arm, tendonitis on left elbow, lead poisoning
I
N
20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip)
20a. COUNTY
J
U
R
Y
22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping department, machine shop.
AGE
21. ON EMPLOYER'S PREMISES?
Yes
DAILY HOURS
No
23. Other Workers injured or ill in this event?
Yes
No
DAYS PER WEEK
24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Acetylene, welding torch, farm tractor, scaffold
O
R
WEEKLY HOURS
25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Welding seams of metal forms, loading boxes onto truck.
I
L
L 26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS, e.g.. Worker stepped back to inspect work
N and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF NECESSARY
E
S
S
27. Name and address of physician (number, street, city, zip)
28. Hospitalized as an inpatient overnight?
No
27a. Phone Number
Yes If yes then, name and address of hospital (number, street, city, zip)
WEEKLY WAGE
COUNTY
NATURE OF INJURY
28a. Phone Number
PART OF BODY
29. Employee treated in emergency room?
Yes
No
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible
while the information is being used for occupational safety and health purposes. See CCR Title 8 14300.29 (b)(6)-(10) & 14300.35(b)(2)(E)2.
SOURCE
Note: Shaded boxes indicate confidential employee information as listed in CCR Title 8 14300.35(b)(2)(E)2*.
30. EMPLOYEE NAME
32. DATE OF BIRTH (mm/dd/yy)
31. SOCIAL SECURITY NUMBER
EVENT
33. HOME ADDRESS (Number, Street, City,Zip)
E
M
P
35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers)
L 34. SEX
O
Male
Female
Y
37a. EMPLOYMENT STATUS
37. EMPLOYEE USUALLY WORKS
E
regular, full-time
E
total weekly hours
days per week,
hours per day,
temporary
SECONDARY SOURCE
36. DATE OF HIRE (mm/dd/yy)
part-time
37b. UNDER WHAT CLASS CODE OF YOUR
POLICY WHERE WAGES ASSIGNED
seasonal
EXTENT OF INJURY
39. OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (e.g. tips, meals, overtime, bonuses, etc.)?
38. GROSS WAGES/SALARY
$
Completed By (type or print)
33a. PHONE NUMBER
per
Signature & Title
Yes
No
Date (mm/dd/yy)
• Confidential information may be disclosed only to the employee, former employee, or their personal representative (CCR Title 8 14300.35), to others for the purpose of processing a workers' compensation or other insurance
. state and
claim; and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 14300.30). CCR Title 8 14300.40 requires provision upon request to certain
federal workplace safety agencies.
FORM 5020 (Rev7) June 2002
FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
State of California
Department of Industrial Relations
DIVISION OF WORKERS’ COMPENSATION
Estado de California
Departamento de Relaciones Industriales
DIVISION DE COMPENSACIÓN AL TRABAJADOR
WORKERS’ COMPENSATION CLAIM FORM (DWC 1)
Employee: Complete the “Employee” section and give the form to
your employer. Keep a copy and mark it “Employee’s Temporary
Receipt” until you receive the signed and dated copy from your em ployer. You may call the Division of Workers’ Compensation and
hear recorded information at (800) 736-7401. An explanation of workers' compensation benefits is included as the cover sheet of this form.
You should also have received a pamphlet from your employer describing workers’ compensation benefits and the procedures to obtain
them.
Any person who makes or causes to be made any knowingly false
or fraudulent material statement or material representation for
the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony.
Employee—complete this section and see note above
PETITION DEL EMPLEADO PARA DE COMPENSACIÓN DEL
TRABAJADOR (DWC 1)
Empleado: Complete la sección “Empleado” y entregue la forma a su
empleador. Quédese con la copia designada “Recibo Temporal del
Empleado” hasta que Ud. reciba la copia firmada y fechada de su empleador.
Ud. puede llamar a la Division de Compensación al Trabajador al (800) 7367401 para oir información gravada. En la hoja cubierta de esta
forma esta la explicatión de los beneficios de compensación al trabajador.
Ud. también debería haber recibido de su empleador un folleto describiendo los
benficios de compensación al trabajador lesionado y los procedimientos para
obtenerlos.
Toda aquella persona que a propósito haga o cause que se produzca
cualquier declaración o representación material falsa o fraudulenta con el
fin de obtener o negar beneficios o pagos de compensación a trabajadores
lesionados es culpable de un crimen mayor “felonia”.
Empleado—complete esta sección y note la notación arriba.
1.
Name. Nombre. _____________________________________________Today’s Date. Fecha de Hoy.
2.
Home Address. Dirección Residencial. _______________________________________________________________________________________
3.
City. Ciudad. _______________________________________ State. Estado. __________________
4.
Date of Injury. Fecha de la lesión (accidente). ________________________ Time of Injury. Hora en que ocurrió. _________a.m. ________p.m.
5.
Address and description of where injury happened. Dirección/lugar dónde occurió el accidente. _________________________________________
___________________________________
Zip. Código Postal. ___________________
_______________________________________________________________________________________________________________________
6.
Describe injury and part of body affected. Describa la lesión y parte del cuerpo afectada. _______________________________________________
_______________________________________________________________________________________________________________________
7.
Social Security Number. Número de Seguro Social del Empleado.
8.
Signature of employee. Firma del empleado.
_______________________________________________________________
_________________________________________________________________________________
Employer—complete this section and see note below. Empleador—complete esta sección y note la notación abajo.
9.
Name of employer. Nombre del empleador. ___________________________________________________________________________________
10. Address. Dirección. _____________________________________________________________________________________________________
11. Date employer first knew of injury. Fecha en que el empleador supo por primera vez de la lesión o accidente. _____________________________
12. Date claim form was provided to employee. Fecha en que se le entregó al empleado la petición. _________________________________________
13. Date employer received claim form. Fecha en que el empleado devolvió la petición al empleador. _______________________________________
14. Name and address of insurance carrier or adjusting agency. Nombre y dirección de la compañía de seguros o agencia adminstradora de seguros.
_______________________________________________________________________________________________________________________
15. Insurance Policy Number. El número de la póliza de Seguro. _____________________________________________________________________
16. Signature of employer representative. Firma del representante del empleador. _______________________________________________________
17. Title. Título. _____________________________________ 18. Telephone. Teléfono. _______________________________________________
Employer: You are required to date this form and provide copies to
your insurer or claims administrator and to the employee, dependent
or representative who filed the claim within one working day of
receipt of the form from the employee.
Empleador: Se requiere que Ud. feche esta forma y que provéa copias a su compañía de seguros, administrador de reclamos, o dependiente/representante de reclamos y al empleado que hayan presentado esta petición dentro del plazo de un día
hábil desde el momento de haber sido recibida la forma del empleado.
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
❑ Employer copy/Copia del Empleador
6/10 Rev.
❑ Employee copy/ Copia del Empleado
❑ Claims Administrator/Administrador de Reclamos
❑ Temporary Receipt/Recibo del Empleado
Need to Report a Claim?
E-mail:
[email protected]
(This is our preferred method of claim reporting)
Phone:
1(800)-774-2755
Press ‘1’ to report a claim
(Available anytime- days, nights & weekends)
Press ‘2’ to inquire about a workers' compensation claim
(Available 8:00am to 5:00pm EST)
Press ‘3’ to inquire about all other claims
(Available 8:00am to 5:00pm EST)
By Fax:
(800)-326-2864
By Mail:
ProSight Specialty Insurance Claims Department
412 Mt. Kemble Avenue
Suite 300C
Morristown, NJ 07960
For more information, visit www.prosightspecialty.com
EXPERIENCED PROFESSIONALS.
INSIGHTFUL SOLUTIONS.SM
Claims Handling Offices | California
Mailing
LWP Claims Solutions, Inc.
P.O. Box 349016
Sacramento, CA 95834-9016
Toll Free: 1-800-565-5694
Phone: 916-609-3600
Fax: 408-725-0395
California
Navigating LWP’s Kaiser Signature
Medical Provider Lookup Website
For Policyholders enrolled in the Kaiser Network, use this
search tool to locate In-Network Medical Providers in
California Only, excluding all other states
•
Go to www.lwpkaisersignaturempn.com
•
The next page will give you four options to choose from:
•
Select by Distance: This option is a radius search from a centralized address.
•
Select by Name: Allows the user to look up a certain provider in the database by name.
•
Regional Listing: This option allows the user to search in a specific region such as city, county, zip
code, etc.
•
Statewide Directory: Enter your e-mail address to recive a statewide directoy of providers.
•
Panel Cards: This option allows the user to make a Panel Card once they have initiated a search
for providers by using on of the methods listed above.
SELECT BY DISTANCE
Begin by selecting the Network you wish to search. Enter your address. You must enter at least a valid ZIP
Code or a City/State combination. At the bottom of the page you may choose: Provider Types, Specialties
and/or distance. Once you click on “find providers” your results will be displayed.
SELECT BY NAME
Use the Name Search tab if you already know a Provider’s name or group affiliation.
REGIONAL LISTING
Use this feature if you are searching for a provider in a specific area.
STATEWIDE DIRECTORY
Use this tab if you are searching for ONLY one of the following: Family Practice, Internal Medicine,
Occupational Medicine, Emergency Medicine and Occupational Medical Clinics within 35 miles of a specific
address.
PANEL CARDS
This page is used to create Panel Cards or batches of Panel Cards. For your convenience, you can choose
providers from one of the three search methods and create a Panel Card for the providers closest to each of
your locations.
Temporary Prescription Services ID
California Only
Attached you will find a prescription form (also called a temporary pharmacy
card) that must be given to each and every employee when there is an on the
job injury. The employee needs to go to one of the pharmacies listed on the
bottom of the form to get their Workers Compensation prescription(s) filled.
They should follow the steps on the top of the form under the heading
“Injured Party.”
It is a good idea to distribute these forms to your Supervisors, Team Leaders,
and your Human Resources department so they are familiar with the form.
Chances are they will receive the notices of injury and will likely be responsible
for handing the form to the injured employee. They need to follow the steps
under the heading “Instructions for Company.”
Prescription Authorization
LWP Claims Solutions, Inc/Workers’ Compensation
LWP Claims Solutions, Inc. and Progressive Medical, Inc. have joined together to provide your eligible injured parties with a First Fill®
prescription medication card program. At the bottom of this form is a First Fill® medication card that enables injured parties to obtain the
“initial” prescription(s) needed upon injury, with little to no out–of–pocket expense.
Instructions for Company to use this First Fill® card:
x
Injury occurs and a report of injury is made to the appropriate personnel.
x
Fill in the eligible injured party’s name, social security number, employer, date of birth, gender and date of injury on the form
below.
x
After explaining the instructions for this card, please give the eligible injured party this document.
x
Instruct the eligible injured party to take the First Fill® card and their prescription to the pharmacy.
x
Report the claim to the appropriate insurance company/TPA.
x
The pharmacist fills the medication; the bill is processed and sent to Progressive Medical.
x
The First Fill® card is available for a one time use.
**Please note: If additional, ongoing medication is required, the claims handler should contact Progressive Medical to utilize our Retail Medication Card
Program.
Injured Party:
At the bottom of this form is a First Fill® Card that will enable you to obtain the “initial” prescription(s) needed upon injury with little to
no out-of-pocket expense. A sample list of “Participating Pharmacy Chains” that accept this First Fill® card is also included below.
This card is for a one time use to receive your medication(s) per your employer/insurance company.
Use of this card is restricted to your allowed condition.
To receive this benefit, present this card to a participating pharmacy along with your prescription from your Doctor.
If you have any questions, call Progressive Medical, toll free, at 1-888-909-MEDS. Out Client Service Specialists are available 24-hours a
day to take care of your needs.
**Please note: If your claim is accepted, you will receive a retail pharmacy card in the mail. Present that card when filling subsequent related
prescriptions.
Participating Pharmacies:
Brooks Pharmacy
Harris Teeter Pharmacy
Rite Aid Pharmacy
CVS Pharmacy
Kmart Pharmacy
Walgreens Pharmacy
Eckerd Pharmacy
Kroger Pharmacy
Wal-Mart Pharmacy
Giant Eagle Pharmacy
Longs Drugs
Winn Dixie Pharmacy
For additional pharmacies in your area, please visit www.progressive-medical.com. Select the Total Pharmacy Management option, then
select the Pharmacy Locator. Enter your City, State, or Zip Code and click the locator button. You will see a listing of all participating
pharmacies within your specified area.
Instructions for Pharmacist:
LWP Claims Solutions, Inc. participates with Progressive Medical in an online pharmacy benefit program. This form is valid for Workers’
Compensation prescriptions only.
Please transmit all claims online to Progressive Medical:
Bin #: 600471
Process Control #: 7777
Group #: A290
__________
For all other questions call toll-free the Progressive Medical Pharmacy Help Desk at 1-888-908-6337.
Injured Worker Information:
Name of Eligible Injured Party:
________________________________________________
ID/Auth # ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
(Combination of Social Security Number – 9 digits, no dashes, and today’s date/date of injury – 6 digits, no dashes; ie., Social Security
Number of 123-45-6789 and Date of Injury July 17, 2006 would be the ID# 123456789071706 )
Date of Birth: __________________
Gender: ________
Employer: ______________________________________________
12 27 07
First Fill
Autorización de medicamentos recetados
LWP Claims Solutions, Inc/Compensación del seguro obrero
LWP Claims Solutions, Inc. y Progressive Medical, Inc. se han unido para proporcionar a las personas lesionadas que califican un
programa de tarjeta de medicamentos recetados “First Fill®”. A pie de página figura una tarjeta de medicamentos First Fill® que permite a
las personas lesionadas obtener la receta o recetas “iniciales” necesarias después de sufrir una lesión sin gastos de su propio bolsillo o con
muy pocos gastos.
Instrucciones para que la Compañía use esta tarjeta First Fill®:
x
Se produce una lesión y se notifica dicha lesión al miembro del personal correspondiente.
x
Se llena el nombre de la persona lesionada que califica, su número de seguro social, empleador, fecha de nacimiento, sexo y
fecha de la lesión.
x
Después de explicar las instrucciones referentes a esta tarjeta, se da este documento a la persona lesionada que califica.
x
Se indica a la persona lesionada que califica que lleve la tarjeta First Fill® y la receta a la farmacia.
x
Se notifica la reclamación a la compañía de seguros o TPA (administrador de terceros) correspondiente.
x
El farmacéutico surte la receta, se procesa la factura y se envía a Progressive Medical.
x
La tarjeta First Fill® está disponible para usarse sólo una vez.
**Nota: Si se requieren más medicamentos para continuar el tratamiento, el encargado de las reclamaciones debe comunicarse con Progressive
Medical para utilizar nuestro Programa de Tarjeta para Medicamentos al Por Menor.
Persona lesionada:
A pie de página figura una tarjeta First Fill® que le permitirá obtener la receta o recetas “iniciales” necesarias después de sufrir una lesión
sin gastos de su propio bolsillo o con muy pocos gastos. Se incluye más adelante una lista de las “Cadenas farmacéuticas participantes” que
aceptan esta tarjeta First Fill®.
Esta tarjeta es para usarse una vez con el fin de recibir el medicamento o medicamentos según su empleador/compañía de seguros
El uso de esta tarjeta se limita a la lesión/problema médico permitido.
Para recibir este beneficio, presente esta tarjeta en una farmacia participante junto con la receta de su médico.
Si tiene alguna pregunta, llame gratis a Progressive Medical al 1-888-909-MEDS. Nuestros especialistas en servicio al cliente se
encuentran a su disposición las 24 horas del día para atender sus necesidades.
**Nota: Si se acepta su reclamación, recibirá por correo una tarjeta para farmacias minoristas. Presente esa tarjeta al surtir recetas posteriores
relacionadas.
Farmacias participantes:
Brooks Pharmacy
Harris Teeter Pharmacy
Rite Aid Pharmacy
CVS Pharmacy
Kmart Pharmacy
Walgreens Pharmacy
Eckerd Pharmacy
Kroger Pharmacy
Wal-Mart Pharmacy
Giant Eagle Pharmacy
Longs Drugs
Winn Dixie Pharmacy
Si desea conocer otras farmacias en su área, visite www.progressive-medical.com. Seleccione la opción Total Pharmacy Management
(Gestión total de farmacias) y, seguidamente, seleccione Pharmacy Locator (Localizador de farmacias). Introduzca su ciudad, estado o
código postal y haga clic en el botón del localizador. Verá una lista de todas las farmacias participantes en un área específica.
Instructions for Pharmacist:
LWP Claims Solutions, Inc. participates with Progressive Medical in an online pharmacy benefit program. This form is valid for Workers’
Compensation prescriptions only.
Please transmit all claims online to Progressive Medical:
Bin #: 600471
Process Control #: 7777
Group #: A290
For all other questions call toll-free the Progressive Medical Pharmacy Help Desk at 1-888-908-6337.
Información sobre el trabajador lesionado:
Nombre de la persona lesionada que califica:
________________________________________________
No. de ID/Autorización ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
[Combinación del número de seguro social (9 dígitos, sin guiones) y la fecha de hoy/fecha de la lesión (6 dígitos, sin guiones); por ejemplo,
el número de seguro social 123-45-6789 y la fecha de lesión del 17 de julio de 2006 daría el número de ID 123456789071706].
Fecha de nacimiento: __________________
Sexo: ________
Empleador: ______________________________________________
Dear Policyholder:
For your convenience, we have included the following website addresses to your state’s
Workers’ Compensation web page. From the links below, you can access any forms that
you might need when submitting a Workers’ Compensation claim.
Alabama
http://dir.alabama.gov
Kentucky
http://www.labor.ky.gov/
North Dakota
http://www.workforcesafety.com/
Alaska
http://www.labor.alaska.gov/wc/
Louisiana
http://www.laworks.net/
Ohio
http://www.ohiobwc.com/
Arizona
http://www.ica.state.az.us/
Maine
http://www.maine.gov/wcb/
Oklahoma
http://www.owcc.state.ok.us/
Arkansas
http://www.awcc.state.ar.us/
Maryland
http://www.wcc.state.md.us/
Oregon
http://www.cbs.state.or.us/wcd/
California
http://www.dir.ca.gov/dwc/
Massachusetts
http://www.state.ma.us/wcac/
Pennsylvania
http://www.portal.state.pa.us
Colorado
http://www.colorado.gov/
Michigan
http://www.michigan.gov/wca
Rhode Island
http://www.dlt.ri.gov/wc/
Connecticut
http://wcc.state.ct.us/
Minnesota
http://www.doli.state.mn.us/
South Carolina
Delaware
http://www.delawareworks.com/
Mississippi
http://www.mwcc.state.ms.us/
South Dakota
http://dlr.sd.gov/workerscomp/
DC
http://www.does.dc.gov/does/
Missouri
http://labor.mo.gov/
Tennessee
http://www.tn.gov/labor-wfd/
Florida
http://www.myfloridacfo.com/wc
Montana
http://erd.dli.mt.gov/
Texas
http://www.tdi.state.tx.us/forms/
Georgia
http://sbwc.georgia.gov/portal/
Nebraska
http://www.wcc.ne.gov
Utah
http://www.laborcommission.utah.gov/
Hawaii
http://hawaii.gov/labor/rs/
Nevada
http://dirweb.state.nv.us/WCS/wcs.htm
Vermont
http://www.labor.vermont.gov/
Idaho
http://www.iic.idaho.gov/
New Hampshire
http://www.labor.state.nh.us/
Virginia
http://www.vwc.state.va.us/portal/
Illinois
http://www.iwcc.il.gov/
New Jersey
http://lwd.state.nj.us/labor/wc/wc_index.html
Washington
http://www.lni.wa.gov/
Indiana
http://www.in.gov/wcb/
New Mexico
http://www.workerscomp.state.nm.us/
West Virginia
http://www.wvinsurance.gov/
Iowa
http://www.iowaworkforce.org
New York
www.wcb.state.ny.us
Wisconsin
http://dwd.wisconsin.gov/wc/
Kansas
http://www.dol.ks.gov/wc/about.html
North Carolina
http://www.ic.nc.gov/forms.html
Wyoming
http://doe.wyo.gov/aboutus/
http://www.wcc.sc.gov/Pages/default.aspx