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.
Claims | Employee Leasing | Self Insurance | Second Injury Fund | Third Party Administrators | Job Modification | Vocational Rehabilitation
Claims
- Notice of Accidental Injury or Occupational Disease (8aWCA, 7-2014)
- Employer's First Report of Occupational Injury or Disease Form (8WC)
- Employer's First Report of Occupational Injury or Disease Form (8WC, 7-2019)
- Memo of Payment of Disability Compensation (9 WCA, 6-1994)
- Wage Schedule (76 WCA, 9-2015)
- Supplemental Wage Schedule Template (76 WCA1, 7-2020)
- Employer's Supplemental Report of Injury (13 WCA, 3-2014)
- Memo of Denial of Workers' Compensation Benefits (9 WCA-1, 9-2015)
- NH Workers' Compensation Medical Forms (75 WCA-1, 6-1994)
- Memo of Permanent Impairment Award (10 WCA, 10-1998)
- Report of Extended Disability (74 WCA, 7-1989)
- NH Workers' Compensation Task Analysis (23-b WC, 9-2015)
- Lump Sum Settlement Forms (15 WCA, 10-1999)
- Release and Settlement of Claim (WC-3PR-1, 6-2015)
- Authorization for Compensation for Death (14WCA, 10-2001)
- Authorization to Permit Witness at Medical Examination (38 WCA, 9-2015)
- Employee's Statement of Employment Status (53WC, 12-2000)
- Notice to Suspend Payment of Workers' Compensation Benefits (53-A, 12-2000)
Employee Leasing
Self Insurance
- Self-Insurance Application (WCSI-1, 2-2016)
- Self-Insurance Application Group (WCSI-1A, 2-2016)
- Self-Insurance Questionnaire (WCSI-16, 9-2015)
- Self-Insurance Surety Bond (WCSI-2, 8-1994)
- Certificate of Insurance (WCSI-4, 1-1992)
- Endorsement (WCSI-5, 4-1996)
- Annual Financial Statement (WCSI-11, 3-1975)
- General Purpose Rider (WCSI-2A, 8-1994)
- Guarantee Proposal (WCSI-1, 1-1992)
- Outstanding Liabilities (WCSI-9, 3-1975)
- Parent Company Agreement (WCSI-6, 1-1992)
- Securities Deposit Agreement (WCSI-3, 1-1992)
- Actuarial Opinion Summary Sheet (WCSI-7, 9-2015)
Second Injury Fund
Third Party Administrators
Job Modification
Vocational Rehabilitation
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 and Chapter LAB 516 Certification of Vocational Rehabilitation Providers for further directions.