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Workers' Compensation Board Forms

To search this catalog: From the toolbar in the Edit menu, select "Find". When the Find search box appears, enter a keyword or form number. The first search result will display with the keyword or number highlighted, at the top of the page. Click "Find next" until the desired form is highlighted.

For forms labeled "PDF", the free Adobe Acrobat Reader software is required to view and in some cases fill them out. Forms in other formats (MS Word, MS Excel, etc) are indicated where appropriate.

To open a form once you have chosen it, click on the linked State Form Number (such as 01365.pdf).

For questions about individual forms, please contact this agency's forms coordinator, Dirinda Asher at 317-232-3822.

For questions about how to use this catalog, or to inform us of a technical problem, please send e-mail to the Forms Management Division.

Forms marked "read-only" cannot be filled in on your computer. They must be printed out and filled in by hand or typewriter.

Title

Form Number
Electronic Format

Agreement to Compensation of Employee and Employer

01043.pdf

Application for Adjustment of Claim (read-only)

29109.pdf

Application for Adjustment of Claim For Provider Fee (read-only)

18487.pdf

Application For Review by Full Board

01042.pdf

Application for Second Injury Fund Benefits (read-only)

51247.pdf

Indiana Worker's Compensation First Report of Employee Injury, Illness (read-only)

34401.pdf

Notice of Inability to Determine Liability / Request For Additional Time (read-only)

48557.pdf

Report of Claim Status/Request for Independent Medical Examination

38911.pdf

Request for Assistance (read-only)

45442.pdf