Common Worker's Comp Forms

Question 1

Form 801 - Report of Job Injury or Illness Purpose

Answer 1

The employer uses this form to report an on-the-job injury.

Question 2

Timeframe for Form 801 - Report of Job Injury or Illness Purpose

Answer 2

It must be submitted to the insurer by the employer within five days of the employer’s date of knowledge of a claim being made.

Question 3

Seven uses for the Form 827 - Workers and Health Care Provider’s report for WC Claim

Answer 3

• First report of an injury or disease (must be sent to the insurer within 72 hours of the initial office visit)
• Request to accept a new or omitted medical condition
• Report of aggravation
• Notice of change of attending physician or nurse practitioner (must be sent to the insurer within 5 days of the office visit)
• Progress report
• Closing report
• Palliative care request

Question 4

Reasons for sending form 1502 - Insurer’s report

Answer 4

• insurer uses the form to report info (including the first report) to the WCD
• New or omitted condition reopening
• Aggravation decision
• reopening for voc training
• litigation ordered acceptance
• change in acceptance or disability status
• correction of previously submitted info
• MCO enrollment after a previously report

Question 5

Time frame for sending 1502 - Insurers report?

Answer 5

14 days from the action that requires the reporting

Question 6

1502 goes to the WCD when?

Answer 6

• Disabling Acceptance
• All Denials including partial denials
• ONLY for NON DISABILING CLAIM IS DENIED

Question 7

Purpose of 1503 - Insurers Notice of Closure summary

Answer 7

• provide notice of claim closure
• provide time loss payment
• provide medical payments
• provide the workers return to work status

Question 8

Timeframe for 1503- Insurers Notice of Closure summary

Answer 8

within 14 days of obtaining info to close claim

Question 9

Purpose of 1644 - Notice of Closure

Answer 9

• Provide notice to the worker of claim closure

- includes extent of benefits, time loss payments, permanent disability (if any) and appeal rights

Question 10

Timeframe for 1644 - Notice of Closure

Answer 10

within 14 days of obtaining info to close claim

Question 11

Purpose of form 2807 - Insurer notice of closure worksheet

Answer 11

Form is used by insurers to calculate disability benefits before entering the info on the 1644

Question 12

Timeframe for 2807 - Insurer notice of closure worksheet

Answer 12

14 days