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Employee Leasing Company Registration Form (EL1).doc
  
EL 1 (Employee Leasing Company Registration Form)EL 1 (Employee Leasing Company Registration Form)11/29/2017 4:08 PMSystem Account
Form 101.doc
  
Form 101Application for Resolution of Injury Claim11/18/2015 2:31 PMSystem Account
Form 102-CWP.doc
  
Form 102-CWPApplication for Resolution of Coal Workers' Pneumoconiosis Claim11/18/2015 2:31 PMSystem Account
Form 102-OD.doc
  
Form 102-ODApplication for Resolution of Occupational Disease Claim11/18/2015 2:31 PMSystem Account
Form 103.doc
  
Form 103Application for Resolution of Hearing Loss Claim11/18/2015 2:31 PMSystem Account
Form 104.doc
  
Form 104Plaintiff's Employment History​11/18/2015 2:32 PMSystem Account
Form 105.doc
  
Form 105Plaintiff's Chronological Medical History11/18/2015 2:32 PMSystem Account
Form 106.doc
  
Form 106Medical Waiver and Consent Form11/18/2015 2:32 PMSystem Account
Form 107-I.doc
  
Form 107-IPhysician's Medical Report-Injury11/18/2015 2:32 PMSystem Account
Form 108-HL.doc
  
Form 108-HLPhysician's Medical Report-Hearing Loss11/18/2015 2:32 PMSystem Account
Form 108-OD.doc
  
Form 108-ODPhysician's Medical Report-Occupational Disease11/18/2015 2:32 PMSystem Account
Form 11.doc
  
Form 11Motion to Substitute Party and Continue Benefits​11/19/2015 8:41 AMSystem Account
Form 110-CWP.doc
  
Form 110-CWPAgreement as to Compensation and Order Approving Settlement for Coal Workers' Pneumoconiosis11/19/2015 8:43 AMSystem Account
Form 110-F.doc
  
Form 110-FAgreement as to Compensation and Order Approving Settlement-Fataility11/19/2015 8:45 AMSystem Account
Form 110-I.doc
  
Form 110-IAgreement as to Compensation and Order Approving Settlement-Injury11/19/2015 8:46 AMSystem Account
Form 110-OD.doc
  
Form 110-ODAgreement as to Compensation and Order Approving Settlement-Occupational Disease11/19/2015 8:47 AMSystem Account
Form 112.doc
  
Form 112Medical Dispute11/18/2015 2:33 PMSystem Account
Form 115.doc
  
Form 115Social Security Release Form11/18/2015 2:33 PMSystem Account
Form SI-01.doc
  
Form SI-01Self-Insurers' Guarantee Agreement2/23/2016 3:06 PMSystem Account
Form SI-02 Attachment.doc
  
Form SI-02 AttachmentSelf Insurance Application Attachment2/23/2016 3:07 PMSystem Account
Form SI-02.doc
  
Form SI-02Self Insurance Application2/23/2016 3:08 PMSystem Account
Form SI-03 Attachment.doc
  
Form SI-03 AttachmentSurety Rider11/3/2017 3:25 PMSystem Account
Form SI-03.doc
  
Form SI-03Continuous Bond2/23/2016 3:11 PMSystem Account
Form SI-04.doc
  
Form SI-04Letter of Credit2/23/2016 3:12 PMSystem Account
Form SI-08.xlsx
  
Form SI-08Loss Report Enclosure A11/6/2017 12:33 PMSystem Account
Lessee Information Form (EL2).doc
  
EL 2 (Lessee Information Form)EL 2 (Lessee Information Form)11/29/2017 4:16 PMSystem Account
Managed Care-UR Form.doc
  
Managed Care-UR FormManaged-Care/Utilization Review2/23/2016 3:14 PMSystem Account
Open Records Request Form.doc
  
Open Records Request FormRequest for copies/inspection of DWC claim files.12/22/2015 11:50 AMSystem Account
Previously Filed Form 4 Request Form.doc
  
Compliance Branch Open Records Request Form(Request Previously Filed Rejection Notices)6/15/2017 2:46 PMSystem Account
Request to Certify Coverage Form.doc
  
Compliance Branch Certification of Coverage Requests(Request Certification of Coverage)6/15/2017 2:46 PMSystem Account
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