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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: RMIS Login.

Checklists

Title Description
Claims Coordinator Checklist (PDF) List of which forms must be sent to SORM, when, and how to submit them. Recommended: make a copy for every new claim, as applicable
Subrogation Checklist (PDF) Important information a claims coordinator can obtain to assist SORM in third-party liability investigations. Recommended: make a copy for every new claim, as applicable.

Forms

Title Description
DWC1S 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.
DWC-3 Employer’s Wage Statement. Online entry is mandatory.
SORM-29 Employee’s Report of Injury (SORM-29)
SORM-80 Employee’s Election Regarding Utilization of Sick and Annual Leave
SORM-80 (PO) Employee’s Election Regarding Utilization of Sick and Annual Leave for Peace Officers (PO).
SORM-74 Witness Statement
DWC-6 Supplemental Report of Injury. Online entry is mandatory.
SORM-16 Authorization for Release of Information
SORM-90 Notification of Additional Information
DWC-48 Travel Reimbursement
Employer Record of Injuries Employer’s Record of Injuries – Agency Violations
SORM-85 Return-to-Work Policy
DWC-73 Work Status Report
Bona Fide Offer Sample Letter Employment Letter
SORM – 703 Incident/Accident Investigation Form RMTSA Guidelines
Workers’ Compensation Trifold Brochure (PDF) Workers’ Compensation Benefits for State Employees

For more information, see

Claims Coordinator Responsibilities

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SORM Publications, Business Links, Legislative Reports, and Policies Links Section

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