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.
(online form)
(download)
(online form)
(download)
Memo of Payment.pdf
Memo of Payment.doc
Memo of Payment of Disablility Compensation (9 WCA)
WageSchedule.pdf
WageSchedule.docWage Schedule (76 WCA 1-94)
Supplemental.pdf
Supplemental.docSupplemental Wage Schedule (76 WCA1)
SupplementalInjury.pdf
SupplementalInjury.docEmployer's Supplemental Report of Injury (13 WCA 7-89)
Memo of Denial.pdf
Memo of Denial.docMemo of Denial of Workers' Compensation Benefits (9 WCA-1 9-02)
Medical form.pdf
Medical form.docNH Workers' Compensation Medical Forms (75 WCA-1 6-94)
Perm Impairment.pdf
Perm Impairment.docMemo of Permanent Impairment Award (10 WCA 10/98)
Extended Disability.pdf
Extended Disability.docReport of Extended Disability (74 WCA 7-89)
Task Analysis.pdf
Task Analysis.docNH Workers' Compensation Task Analysis
Lump Sum.pdf
Lump Sum.docLump sum Settlement Forms (15 WCA (10-99)
Release-Settlement.pdf
Release-Settlement.docRelease and Settlement of Claim (WC-3PR-1 7-89)
Compensation-Death.pdf
Compensation-Death.docAuthorization for Compensation for Death
WORKERS' COMPENSATION COVERAGE FORMS
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
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.docNH Vocational Rehabilitation Provider Certification Form
IWRP.pdf
IWRP.docIndividual Written Rehabilitation Plan (IWRP)
Rehab Training.pdf
Rehab Training.docVocational Rehabilitation Training Agreement
Rehab Closure.pdf
Rehab Closure.docRehabilitation Closure Form
Rehab Referral.pdf
Rehab Referral.docRehabilitation Referral Form
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