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Medical Control
The injured employee may select an initial medical provider of his/her choice
unless the employer has selected a Managed Care Network. When subject to
the Managed Care Network, the employer has the right to direct medical
care for the life of the claim. A change of medical provider may be made
within the Managed Care Network. The employee may select his/her own
pharmacy or select a pharmacy from the Express Scripts pharmacy
network. Emergency medical care should be secured at the nearest location.
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 .
WORKERS' COMPENSATION CLAIMS FORMS
Most of our forms are in the format of Adobe Portable Document (.pdf)
which will require Acrobat Reader to display the forms within your
browser. We have included some forms in the Microsoft Word (.doc)
format. These forms can be downloaded onto your system so you can create
an on-line form.
• Employer's First Report of Occupational Injury or Disease Form (8WC)
(online form)
• Notice of Accidental Injury Or Occupational Disease (8aWCA)
(online form)
• Notice of Accidental Injury Or Occupational Disease (8aWCA)
(download)
Memo of Payment.pdf Memo of Payment.doc
Memo of Payment of Disability Compensation (9 WCA)
WageSchedule.pdf WageSchedule.doc
Wage Schedule (76 WCA 1-94)
Supplemental.pdf Supplemental.doc
Supplemental Wage Schedule (76 WCA1)
SupplementalInjury.pdf SupplementalInjury.doc
Employer's Supplemental Report of Injury (13 WCA 7-89)
Memo of Denial.pdf Memo of Denial.doc
Memo of Denial of Workers' Compensation Benefits (9 WCA-1 9-02)
Medical form.pdf Medical form.doc
NH Workers' Compensation Medical Forms (75 WCA-1 6-94)
Perm Impairment.pdf Perm Impairment.doc
Memo of Permanent Impairment Award (10 WCA 10/98)
Extended Disability.pdf Extended Disability.doc
Report of Extended Disability (74 WCA 7-89)
Task Analysis.pdf Task Analysis.doc
NH Workers' Compensation Task Analysis
Lump Sum.pdf Lump Sum.doc
Lump sum Settlement Forms (15 WCA (10-99)
Release-Settlement.pdf Release-Settlement.doc
Release and Settlement of Claim (WC-3PR-1 7-89)
Compensation-Death.pdf Compensation-Death.doc
Authorization for Compensation for Death
Authorization_to_Permit_Witness_at_Medical_Exam.pdf
Authorization_to_Permit_Witness_at_Medical_Exam.doc
Authorization to Permit Witness at Medical Examination
• Employee's Statement of Employment Status (53WC)
• Notice to Suspend Payment of Workers' Compensation
Benefits (53-A)
WORKERS' COMPENSATION COVERAGE FORMS
• Coverage Questionnaire Form (online form)
SELF-INSURANCE FORMS
• 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
SECOND INJURY FUND FORMS
• Application for Second Injury Fund
• Request for Reimbursement from the Second Injury Fund Request for
Reimbursement from the Second Injury Fund.doc
• Schedule of Reimbursable Payments Schedule of Reimbursable
Payments.doc
• 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 ADMINISTRATOR FORMS
• 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 REIMBURSEMENT FORMS
• Request for Job Modification Plan Approval
• Request for Job Modification Plan Approval
VOCATIONAL REHABILITATION FORMATS
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 for further directions.
Rehab Provider Cert.pdf Rehab Provider Cert.doc
NH Vocational Rehabilitation Provider Certification Form
IWRP.pdf IWRP.doc
Individual Written Rehabilitation Plan (IWRP)
Rehab Training.pdf Rehab Training.doc
Vocational Rehabilitation Training Agreement
Rehab Closure.pdf Rehab Closure.doc
Rehabilitation Closure Form
Rehab Referral.pdf Rehab Referral.doc
Rehabilitation Referral Form
The injured employee may select an initial medical provider of his/her choice
unless the employer has selected a Managed Care Network. When subject to
the Managed Care Network, the employer has the right to direct medical
care for the life of the claim. A change of medical provider may be made
within the Managed Care Network. The employee may select his/her own
pharmacy or select a pharmacy from the Express Scripts pharmacy
network. Emergency medical care should be secured at the nearest location.
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 .
WORKERS' COMPENSATION CLAIMS FORMS
Most of our forms are in the format of Adobe Portable Document (.pdf)
which will require Acrobat Reader to display the forms within your
browser. We have included some forms in the Microsoft Word (.doc)
format. These forms can be downloaded onto your system so you can create
an on-line form.
• Employer's First Report of Occupational Injury or Disease Form (8WC)
(online form)
• Notice of Accidental Injury Or Occupational Disease (8aWCA)
(online form)
• Notice of Accidental Injury Or Occupational Disease (8aWCA)
(download)
Memo of Payment.pdf Memo of Payment.doc
Memo of Payment of Disability Compensation (9 WCA)
WageSchedule.pdf WageSchedule.doc
Wage Schedule (76 WCA 1-94)
Supplemental.pdf Supplemental.doc
Supplemental Wage Schedule (76 WCA1)
SupplementalInjury.pdf SupplementalInjury.doc
Employer's Supplemental Report of Injury (13 WCA 7-89)
Memo of Denial.pdf Memo of Denial.doc
Memo of Denial of Workers' Compensation Benefits (9 WCA-1 9-02)
Medical form.pdf Medical form.doc
NH Workers' Compensation Medical Forms (75 WCA-1 6-94)
Perm Impairment.pdf Perm Impairment.doc
Memo of Permanent Impairment Award (10 WCA 10/98)
Extended Disability.pdf Extended Disability.doc
Report of Extended Disability (74 WCA 7-89)
Task Analysis.pdf Task Analysis.doc
NH Workers' Compensation Task Analysis
Lump Sum.pdf Lump Sum.doc
Lump sum Settlement Forms (15 WCA (10-99)
Release-Settlement.pdf Release-Settlement.doc
Release and Settlement of Claim (WC-3PR-1 7-89)
Compensation-Death.pdf Compensation-Death.doc
Authorization for Compensation for Death
Authorization_to_Permit_Witness_at_Medical_Exam.pdf
Authorization_to_Permit_Witness_at_Medical_Exam.doc
Authorization to Permit Witness at Medical Examination
• Employee's Statement of Employment Status (53WC)
• Notice to Suspend Payment of Workers' Compensation
Benefits (53-A)
WORKERS' COMPENSATION COVERAGE FORMS
• Coverage Questionnaire Form (online form)
SELF-INSURANCE FORMS
• 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
SECOND INJURY FUND FORMS
• Application for Second Injury Fund
• Request for Reimbursement from the Second Injury Fund Request for
Reimbursement from the Second Injury Fund.doc
• Schedule of Reimbursable Payments Schedule of Reimbursable
Payments.doc
• 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 ADMINISTRATOR FORMS
• 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 REIMBURSEMENT FORMS
• Request for Job Modification Plan Approval
• Request for Job Modification Plan Approval
VOCATIONAL REHABILITATION FORMATS
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 for further directions.
Rehab Provider Cert.pdf Rehab Provider Cert.doc
NH Vocational Rehabilitation Provider Certification Form
IWRP.pdf IWRP.doc
Individual Written Rehabilitation Plan (IWRP)
Rehab Training.pdf Rehab Training.doc
Vocational Rehabilitation Training Agreement
Rehab Closure.pdf Rehab Closure.doc
Rehabilitation Closure Form
Rehab Referral.pdf Rehab Referral.doc
Rehabilitation Referral Form
West Virginia
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January 17, 2012: New Hampshire News:
Mileage Reimbursement Rate
Mileage Reimbursement Rate