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Copyright 2001 State of New Hampshire		 Ask Dolli/Site Search  

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 This document requires the free Adobe Acrobat Reader available by clicking on this icon..

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.

Notice of Accidental Injury Or Occupational Disease (8aWCA) (online form)

Notice of Accidental Injury Or Occupational Disease (8aWCA)

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Employer's First Report of Occupational Injury or Disease Form (8WC) (online form)

Memo of Payment of Disability Compensation (9 WCA)

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Wage Schedule (76 WCA 1-94)

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Supplemental Wage Schedule (76 WCA1)

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Employer's Supplemental Report of Injury (13 WCA 7-89)

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Memo of Denial of Workers' Compensation Benefits (9 WCA-1 9-02)

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NH Workers' Compensation Medical Forms (75 WCA-1 6-94)

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Memo of Permanent Impairment Award (10 WCA 10/98)

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Report of Extended Disability (74 WCA 7-89)

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NH Workers' Compensation Task Analysis

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Lump sum Settlement Forms (15 WCA (10-99)

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Release and Settlement of Claim (WC-3PR-1 7-89)

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Authorization for Compensation for Death

This document requires the free Adobe Acrobat Reader.

Authorization to Permit Witness at Medical Examination

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Employee's Statement of Employment Status (53WC)

This document requires the free Adobe Acrobat Reader.

Notice to Suspend Payment of Workers' Compensation Benefits (53-A)

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WORKERS' COMPENSATION COVERAGE FORMS

  • Coverage Questionnaire Form (online form)

    SELF-INSURANCE FORMS

    Self-Insurance Application

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    Self-Insurance Questionnaire

    This document requires the free Adobe Acrobat Reader.

    Self-Insurance Surety Bond

    This document requires the free Adobe Acrobat Reader.

    Certificate of Insurance

    This document requires the free Adobe Acrobat Reader.

    Endorsement

    This document requires the free Adobe Acrobat Reader.

    Annual Financial Statement

    This document requires the free Adobe Acrobat Reader.

    General Purpose Rider

    This document requires the free Adobe Acrobat Reader.

    Guarantee Proposal

    This document requires the free Adobe Acrobat Reader.

    Outstanding Liabilities

    This document requires the free Adobe Acrobat Reader.

    Parent Company Agreement

    This document requires the free Adobe Acrobat Reader.

    Securities Deposit Agreement

    This document requires the free Adobe Acrobat Reader.

    Securities Deposit Agreement Past Liability

    This document requires the free Adobe Acrobat Reader.

    SECOND INJURY FUND FORMS

    Application for Second Injury Fund

    This document requires the free Adobe Acrobat Reader.

    Request for Reimbursement from the Second Injury Fund

    This document requires the free Adobe Acrobat Reader.

    Schedule of Reimbursable Payments

    This document requires the free Adobe Acrobat Reader.

    Second Injury Fund Affidavit of Employer Knowledge

    This document requires the free Adobe Acrobat Reader.

    Second Injury Fund Certification by Physician

    This document requires the free Adobe Acrobat Reader.

    Application for Reimbursement of Paid Adjusted Total Disability

    This document requires the free Adobe Acrobat Reader.

    Application for Reimbursement of Paid Combined Earnings

    This document requires the free Adobe Acrobat Reader.

    THIRD PARTY ADMINISTRATOR FORMS

    Security Deposit Agreement for Third Party Administrator

    This document requires the free Adobe Acrobat Reader.

    Application for Certificate of Authority

    This document requires the free Adobe Acrobat Reader.

    Notice of Contract Between Third Party Administrator and Self Insurer

    This document requires the free Adobe Acrobat Reader.

    Third Party Administration Bond

    This document requires the free Adobe Acrobat Reader.

    Biographical Affidavit

    This document requires the free Adobe Acrobat Reader.

    JOB MODIFICATION REIMBURSEMENT FORMS

    Request for Job Modification Plan Approval

    This document requires the free Adobe Acrobat Reader.

    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 This link is to a page outside of the NH DOL web site. NH DOL assumes no responsibility for its content. for further directions.

    NH Vocational Rehabilitation Provider Certification Form

    This document requires the free Adobe Acrobat Reader.

    Individual Written Rehabilitation Plan (IWRP)

    This document requires the free Adobe Acrobat Reader.

    Vocational Rehabilitation Training Agreement

    This document requires the free Adobe Acrobat Reader.

    Rehabilitation Closure Form

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    Rehabilitation Referral Form

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