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.

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

Medical mileage form

Medical Mileage Expense Form 2026

For mileage that occurs in 2026, the rate is 72.5 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 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.

Prior Medical Mileage Expense Forms

Locate the Medical Mileage Expense Forms starting in 2022.

Workers' Compensation claim forms

Workers’ Compensation claim form (DWC 1)

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.

Employer's report of occupational injury or illness (Form 5020)

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.