Workers' Compensation Division Forms

The forms listed below are the official New Hampshire State Forms. Your insurance carrier is responsible for supplying the Workers' Compensation forms. Most of the forms are discussed in detail in the Employer's Guide to Workers' Compensation .

Claims | Self Insurance | Second Injury Fund | Third Party Administrators | Job Modification | Vocational Rehabilitation

Claims

• Notice of Accidental Injury or Occupational Disease (8aWCA)
• Employer's First Report of Occupational Injury or Disease Form (8WC)
• Employer's First Report of Occupational Injury or Disease Form (8WC)
• Memo of Payment of Disability Compensation (9 WCA)
• Wage Schedule (76 WCA 1-94)
• Supplemental Wage Schedule (76 WCA1)
• Employer's Supplemental Report of Injury (13 WCA 7-89)
• Memo of Denial of Workers' Compensation Benefits (9 WCA-1 9-02)
• NH Workers' Compensation Medical Forms (75 WCA-1 6-94)
• Memo of Permanent Impairment Award (10 WCA 10/98)
• Report of Extended Disability (74 WCA 7-89)
• NH Workers' Compensation Task Analysis
• Lump Sum Settlement Forms (15 WCA (10-99)
• Release and Settlement of Claim (WC-3PR-1 7-89)
• Authorization for Compensation for Death
• Authorization to Permit Witness at Medical Examination
• Employee's Statement of Employment Status (53WC)
• Notice to Suspend Payment of Workers' Compensation Benefits (53-A)

Self Insurance

• Self-Insurance Application
• Self-Insurance Questionnaire
• Self-Insurance Surety Bond
• Certificate of Insurance
• Endorsement
• Annual Financial Statement
• General Purpose Rider
• Guarantee Proposal
• Outstanding Liabilities
• Parent Company Agreement
• Securities Deposit Agreement
• Securities Deposit Agreement Past Liability

Second Injury Fund

• Application for Second Injury Fund
• Request for Reimbursement from the Second Injury Fund
• Schedule of Reimbursable Payments
• Second Injury Fund Affidavit of Employer Knowledge
• Second Injury Fund Certification by Physician
• Application for Reimbursement of Paid Adjusted Total Disability
• Application for Reimbursement of Paid Combined Earnings

Third Party Administrators

• Security Deposit Agreement for Third Party Administrator
• Application for Certificate of Authority
• Notice of Contract Between Third Party Administrator and Self Insurer
• Third Party Administration Bond
• Biographical Affidavit

Job Modification

• Request for Job Modification Plan Approval

Vocational Rehabilitation

These are the formats a CVRP is required to follow when submitting these required documents to the New Hampshire Department of Labor. Please refer to New Hampshire Administrative Rules Chapter LAB 509 Vocational Rehabilitation and Chapter LAB 516 Certification of Vocational Rehabilitation Providers for further directions.

• NH Vocational Rehabilitation Provider Certification Form
• Individual Written Rehabilitation Plan (IWRP)
• Vocational Rehabilitation Training Agreement
• Rehabilitation Closure Form
• Rehabilitation Referral Form