Claims Coordinator Handbook Forms and Checklists
Some of the below listed forms are available for online
entry! This online system can be accessed through the login
page located at:
* NOTE: These forms are in Adobe Acrobat format. You
must have the free
| Forms |
| Title |
Description |
File Type |
| DWC-1S |
Employer's First
Report of Injury or Illness and must be received by SORM
not later than the 5th calendar day after the injured
employee first reports the injury to the employing agency.
Online entry is mandatory. |
HTML, PDF
Online
Entry |
| DWC-3 |
Employer's Wage
Statement. Online entry is mandatory. |
HTML, PDF
Online
Entry |
| SORM-29 |
Employee's Report
of Injury (SORM-29). SORM-29 is available in English and Spanish - Revised 7/2009 |
Word, PDF |
| SORM-80 |
Employee's Election
Regarding Utilization of Sick and Annual Leave. Revised 11/2011 |
Word, PDF |
| SORM-80
(PO) |
Employee's Election
Regarding Utilization of Sick and Annual Leave for Peace
Officers (PO). Revised 11/2011 |
Word, PDF |
| SORM-74 |
Witness Statement. SORM-74 is available in English and Spanish - Revised 7/2009 |
Word, PDF |
| DWC-6 |
Supplemental
Report of Injury. Online entry is mandatory. |
HTML, PDF
Online
Entry |
| SORM-16 |
Authorization
for Release of Information. SORM-16 is available in English and Spanish - Revised 7/2009 |
Word, PDF |
| SORM-90 |
Notification
of Additional Information
Revised: Feb. 2004 |
HTML, PDF
Online
Entry |
| DWC-48 |
Travel Reimbursement |
HTML, PDF |
| SORM-100 |
All Changes in Designation of Claims Coordinator must be completed online through RMIS |
HTML (information only) |
| Employer
Record of Injuries |
Employer's Record
of Injuries - Agency Violations |
|
| SORM-85 |
Return-to-Work
Policy |
PDF |
| DWC-73 (scroll
down the page to Health Care Provider/Medical Forms) |
Work Status Report |
PDF |
| Bona
Fide Offer Sample Letter |
Employment Letter |
PDF, Word |
| SORM - 703 |
Incident/Accident Investigation Form |
RMTSA Guidelines |
|
|
