Utilities and Forms
EnhanceGuru has gathered most of the Indiana guides, forms and calculators to manage the work comp process
To contact the Worker's Compensation Board of Indiana directly:
Worker's Compensation Board of Indiana
402 West Washington Street Room W-196
Indianapolis, Indiana 46204
Phone: 800-824-COMP or 317-232-3808
Guidelines/ Calculations:
OSHA 300-A Summary posting requirements
2011 2nd Injury Recommendation Report.pdf
2010 Second Injury Fund Calculation of Funding Level.pdf
Amish and Work Comp Board Agreement.pdf
Amish Certificate of Compliance.pdf
Comparison of Benefits and Rates to Inflation Over Time.pdf
Indiana Workers Compensation Premium Algorithm.pdf
Compensation Table for Multiple Digit Loss to the Hand form.pdf
PPI Weekly Benefits(Information on Permanent Partial Impairment and Weekly Benefits).pdf
www.disability.gov/employment/news
General Info:
Indiana Workers Compensation Districts.pdf
Workers Compensation Application.pdf
Workers Compensation Notice SPANISH.pdf
IN WC Board's technology amendments (PDF)
IN WC Board Economic Impact Statement (PDF)
Forms:
New - Employee Waiver of Examination by Personal Physician.pdf - Form 53913
Explantation of Forms & Benefits.pdf
Agreement to Compensation of Employee & Employer.pdf
Notice of Suspension of Medical Benefits.pdf
Notice of Denial of Benefits.pdf
Report of TDD/TPD - Termination/Reduction.pdf
Work Comp Notice Poster - English.pdf
1042 Application for Review by Full Board.pdf
1043 Agreement to Compensation of Employee and Employer.pdf
2118 Report of Attending Physican.pdf
12386 Self-Insured Employer Certification.pdf
12386b Certification for Workers Compensation Carriers.pdf
18487 Application for Adjustment of Claim for Provider Fee.pdf
18875 Agreement to Compensation Between the Dependents of Deceased Employee and Employer.pdf
29109 Application for Adjustment of Claim.pdf
34401 First Report of Injury Form.pdf34873 Agreement Between Parties for Lump Sum Payment.pdf
36097 Notice of Workers Compensation And Occupational Diseases Coverage.pdf
38911 Report of Claims Status Request for Independent Medical Examination.pdf
45442 Request for Assistance.pdf
45899 Application For Workers Compensation Clearance Certificate SPANISH.pdf
45899 Application For Workers Compensation Clearance Certificate.pdf
54217 Notice of Suspension of Medical Benefits.pdf
ERM-6 Form Workers Compensation Experience Rating For Non-Affiliate Data.pdf
ERM-14 Confidential Request for Ownership Information.pdf
Self Insured Employer Forms
2011 Self-Insurance Application for New & Renewal Applicants
2011 Self-Insurance Guidelines
2010 Self-Insurance Application for New & Renewal Applicants
2010 Self-Insurance Guidelines
Surety Bond Form
Certificate of Excess Insurance
Subsidiary Application
Parental Indemnity Agreement
Truckers Supplemental Application
These utilities are provided as a reference only and are not to be interpreted as legal advice for a worker’s compensation claim. They may be utilized as a guide and may be able to provide clarification on worker’s compensation terminology and processes. Those seeking legal council should contact the Indiana Work Comp board at www.in.gov/wcb and/or seek the advice of a legal professional.
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