* NOTE: Use the free program, Adobe Acrobat, to open PDFs.
This form should always be filled out by the injured employee and filed with SORM. This will help to expedite benefits in a more timely manner.
The form must be received by SORM not later than the 5th calendar day after the First Report of Injury or Illness (DWC-1S) is reported to the agency.
The claimant, with assistance from the claims coordinator.
All fields should be completed in detail and printed legibly. Make sure that the claimant signs and dates the bottom of the form.
Fax a copy or mail the original to:
State Office of Risk Management
Retain a copy for your file.