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West Virginia Forms

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 73 State Forms found

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Application for Permanent Total Disability Benefits

OIC-115 07/2013

Claim Re-opening Application for Temporary Total Disability or Medical Treatment

 OIC-125 5/16

Claim Re-Opening Application for Permanent Partial Disability

 No Form Number Revised 5/2016

2018 SELF-INSURED EMPLOYER CONTACT INFORMATION

 No Form Number 2018

Attending Physician’s Report (Encova)

 WC-5228 06-20

Change of Address Notification (Encova)

 WC-5249 06-20

Claimant Travel Voucher (Encova)

 WC-5250 06-20

Employer’s Report of Injury (BrickStreet)

 BI-3 06/17

West Virginia Workers’ Compensation Employees’ and Physician’s Report of Occupational Injury or Disease (Encova)

 BI-1 07-20

Job Function Evaluation (Encova)

 WC-5246 06-20

Job Analysis Form (Encova)

 WC-5245 06-20

Pharmacy Invoice (Encova)

 WC-5254 06-20

Physician Statement of Physical Capabilities (Encova)

 WC-5235 06-20

Physician's Roentgenographic Interpretation Report of Occupational Pneumoconiosis (Encova)

 WC-5237 06-20

Service Invoice (Encova)

 WC-5239 06-20
Disclaimer: These forms may not be the most recent version. West Virginia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.
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