Workers' Compensation

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  Affidavit in Support of Redemption (Settlement) Agreement

  MIBWC-119 $69.00
• 

  Aggregate Claims Administration Change Report

  FLWC49 $69.00
• 

  Aggregate Defense Attorney Fee Report

  FLWC51 $69.00
• 

  Agreement Between Employer/Employee Choice of Phy

  TNWC_C-42 $39.00
• 

  Agreement for Compensation for Disability

  NCWC21 $69.00
• 

  Agreement for Permanent Disability/Disfigurement Compensation

  SCWC16 $69.00
• 

  Agreement to Pay Benefits

  VAWC-4 $89.00
• 

  AL WC: Supplementary Report

  ALWC3 $89.00
• 

  Amputation Chart

  MIBWC-728 $89.00
• 

  Annual Consolidated Fiscal Report of Medical

  NCWC51 $69.00
• 

  Answer

  MSWCB5-22 $69.00
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  Aplicación Para Beneficios de Ingresos Suplementales

  TWCC-52S $179.00
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  Appearance of Representative

  ILIC6 $89.00
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  Application for a Division Independent Medical Examination

  COWC77 $89.00
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  Application for a Fee by Claimant’s Attorney or Representative

  NYWC_OC-400.1 $89.00
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  Application for Acceptance of Insurance Form

  NYWCDB850 $69.00