Workers' Compensation

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  Fraud and Compliance Request for Hearing or Trial Division Intervention

  GAWC24 $89.00
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  General Admission of Liability

  COWC2 $89.00
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  Health Care Notice for Employees Under Managed Care

  ARWCH $39.00
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  Health Insurance Claim Form

  CMS1500 $149.00
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  Illinois IC Reporting Forms

  ILICFORMS $375.00
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  Illinois Initial IC Reporting Forms (IC-45, IC-85)

  ILIC45P85 $129.00
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  Illinois WC Forms Package

  ILWCPack $375.00
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  In-Patient Utilization Review Closure

  TNWC_C-36/37 $89.00
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  Individualized Rehabilitation Plan

  GAWCR2A $129.00
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  Individualized Written Re-Employment Plan

  FLWC20 $89.00
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  Initial Claim for Workers’ Compensation Benefits

  VAWC-5 $89.00
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  Itemized Statement of Charges for Drugs

  NCWC25P $69.00
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  Itemized Statement of Charges for Travel

  NCWC25T $89.00
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  Job Analysis

  GAWC240A $69.00
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  Lump Sum Petition

  NMWCLSP $69.00
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  Maximum Medical Improvement/Permanent Impairment Determination Certification

  FLWC9A $89.00