Complete Form List (numbered)
Form 46A - Request For Section 46A Conference in Conjunction With Lump Sum Under Section 48
Form 101 - Employer's First Report of Injury/Fatality
Updated 5/21/2009
Form 103 - Insurer's Notification of Payment
Updated 9/04
Form 104 - Insurer's Notification of Denial
Updated 8/2001
Form 105 - Agreement to Extend 180 Day Payment-Without-Prejudice Period
Updated 11/2001
Form 106 - Insurer's Notification of Termination or Modification of Weekly Compensation During Payment-Without-Prejudice Period
Updated 8/2001
Form 107 - Insurer's Notification of Acceptance, Resumption, Termination or Modification of Weekly Compensation
Updated 8/2001
Form 108 - Insurer's Complaint for Modification, Discontinuance or Recoupment of Compensation
Updated 11/2001
Form 109 - Notification of Withdrawal of Claim or Complaint
Updated 8/2001
Form 110 - Employee Claim
Updated 5/21/2009
Form 112 - Appeal to Reviewing Board
Updated 8/2001
Form 112A - Affidavit in Support of Request for Waiver of Filing Fee Under Section 11C
Updated 8/2001
Form 113 - Agreement to Pay Compensation
Updated 4/2009
Form 114 - Notice of Change/Appearance of Counsel
Updated 8/2001
Form 115 - Third Party Claim/Notice of Lien
Updated 8/2001
Form 116 - Request for Lump Sum Conference
Updated 5/21/2009
Form 116A - Employer Consent to Lump Sum Agreement
Updated 8/2001
Form 116B - Addendum to Lump Sum Agreement: Vocational Rehabilitation Status
Updated 8/2001
Form 116C - Lien Disclosure Form
Updated 8/2001
Form 117 - Agreement for Redeeming Liability by Lump Sum for Injuries On or After Nov. 1, 1986
Updated 8/2001
Form 117A - Agreement for Redeeming Liability by Lump Sum for Injuries Before Nov. 1, 1986
Updated 8/2001
Form 118 - Medical-Only - The DIA no longer supplies this form.
The DIA no longer supplies this form. For a medical-only claim you would use whatever form your insurance carrier suplies to you. This form is NOT sent to the DIA.
Form 121 - Appeal of Conference Order
Updated 8/2001
Form 121A - Agreement That No Impartial Physician Report is Required
Updated 8/2001
Form 122 and Form 123 - Request for Sections 37/37A Proceedings/Agreement Forms
Form 122 Updated 11/2001
Form 123 Updated 11/2006Form 124A - Notification of Arbitration Award
Updated 8/2001
Form 125 - Motion for Expedited Conference
Updated 2/2007
Form 126 - Employee Earning Report
Updated 8/2001
Form 127 - Average Weekly Wage Computation Schedule
Form 130 - Complaint of Improper Claims Handling Against an Insurer
Updated 8/2001
Form 131 - Request for Speedy Conference Because of Hardship
Updated 8/2001
Form 132 - Affidavit in Support of Employee's Request for Speedy Conference Because of Hardship
Updated 8/2001
Form 133A - Utilization Review (UR) Agent Complaint
Updated 10/2004
Form 134 - Health Care Provider Complaint
Updated 7/2001
Form 136 - Affidavit of Indigence and Request for Waiver of Sec. 11A(2) Fees
Updated 8/2001
Form 140 - Temporary Conference Memorandum Cover Sheet
Updated 8/2001
Form 141 - Last Best Offer at Conference
Updated 8/2001
Form 151 - Individual Written Rehabilitation Program Form
Updated 8/2001.
Form 152 - Amendment/Suspension or Closure of Vocational Rehabilitation Plan
Updated 9/2009
Form 153 - Affidavit of Exemption for Certain Corporate Officers or Directors
Updated 10/2002
Form 160 - Employee's Biographical Data Sheet
Updated 8/2001
Form 161 - Employee's Hearing Memorandum
Updated - 8/2004
Form 162 - Insurer's Hearing Memorandum
Updated 8/2004
Form 170 - Affidavit of Employee in Application for Trust Fund Benefits
Updated - 11/2002