RESOURCE COLLECTION

Workers' Compensation forms

Find the forms that you need for workers' compensation claims and approval.

Human Resources

Documents

Electronic payment initiative

Claimant Payment Preference Form

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

Medical mileage form

Medical Mileage Expense Form 2025

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.

Medical Mileage Expense Form 2024

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.

Medical Mileage Expense Form 2023

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.

Medical Mileage Expense Form 2022

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.

Pre-designation of a physician

Pre-Designation of Physician form - English

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

Pre-Designation of physician form - Spanish

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

Work assignment agreement

Temporary Transitional Work Assignment Agreement

Resources