工人賠償表格

Opt out of electronic payments, or make changes to your payment preference.

For mileage that occurs in 2025, the rate is 70 cents per mile. Use this form to claim your mileage or travel reimbursement by sending a completed copy to your claim examiner.

For mileage that occurs in 2024, the rate is 67 cents per mile. Use this form to claim your mileage or travel reimbursement by sending a completed copy to your claim examiner.

For mileage that occurs in 2023, the rate is 65.5 cents per mile. Use this form to claim your mileage or travel reimbursement by sending a completed copy to your claim examiner.

For mileage that occurs after 7/1/2022, the rate is 62.5 cents per mile. Use this form to claim your mileage or travel reimbursement by sending a completed copy to your claims examiner.

Choose your own medical doctor for a work-related injury or illness. (Form in English)

Choose your own medical doctor for a work-related injury or illness. (Form in Spanish)

Complete and send the form to EMPLOYERS to initiate the claim process for your employee. This form must be completed and provided to EMPLOYERS within 1 working day from a work-related injury or occupational disease.

The employer is required to file a complete report of every occupational injury or illness to each employee which results in lost time past the date of injury or illness or which requires medical treatment beyond first aid.