The Purpose and Use of the Most Common Workers' Compensation Forms Flashcards
What is the purpose of Form 801 - Report of Job Injury or Illness?
The employer uses this form to report an on-the-job injury.
What is the timeframe for sending Form 801 to insurer?
It must be submitted to the insurer by the employer within five days of the employer’s date of knowledge of a claim being made.
What are the seven uses for the Form 827 —Worker’s and Health Care Provider’s report for Workers’ Compensation Claim?
- First report of an injury or disease
- Request to accept a new or omitted medical condition
- Report of aggravation
- Notice of change of attending physician or nurse practitioner (must be sent to the insurer within 5 days of the office visit)
- Progress report
- Closing report
- Palliative care request
What are the reasons for the Form 1502 —Insurer’s Report?
The insurer uses this form to report information to WCD including:
first report of a claim decision for disabling acceptances and all denials including partial denials,
new or omitted condition reopening,
aggravation decision,
reopening for voc training,
litigation ordered acceptance,
change in acceptance or disability status,
correction of previously submitted info,
MCO enrollment after a previous report.
What is the timeframe for sending the Form 1502 to WCD?
The insurer must submit within 14 days of the action that requires reporting
When should a Form 1502 be sent in a nondisabling claim?
A 1502 only if the nondisabling claim is denied.
What is the purpose of the Form 1503 —Insurer Notice of Closure Summary?
The insurer uses this form to provide notice to the WCD of the insurer’s claim closure and includes time loss payments, medical payments, and the worker’s return to work status.
When should Form 1503 be sent to WCD?
It must be submitted within 14 days of obtaining information needed to close a claim.
What is the purpose of the Form 1644 —Notice of Closure?
The insurer uses this form to provide notice to the worker of claim closure and includes extent of benefits, time loss payments, permanent disability, if any, and appeal rights.
When should Form 1644 be sent to WCD?
It must be submitted within 14 days of obtaining information needed to close a claim.
What is the purpose of the Form 2807 —Insurer Notice of Closure Worksheet
The form is used by insurers to calculate disability benefits before entering the information on to the Form 1644 –Notice of Closure.
When should Form 2807 be sent to WCD?
It must be submitted within 14 days of obtaining information needed to close a claim.
Examples of subject workers
Domestic servants
Person hired to do gardening or maintenance in a private home
Firefighters or policy in a city having more than 200k people
News paper carrier
Person performing foster parent duties
