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Indiana Workers’ Compensation Forms

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Form 1043: Agreement to Compensation of Employee and Employer
This form is filed when the injured employee and their employer reach an understanding on payment of temporary total disability. When this form is approved by the Board, it constitutes an Award. When an agreement to compensation on an award for permanent partial impairment is reached, this form is filed again.

Form 18875: Agreement to Compensation Between the Dependents of Deceased Employee and Employer
This form is filed in the case of a compensable death in order for the decedent’s benefits to be distributed among the dependents.

Form 38911: Report of Claim Status/Request for Independent Medical Examination

This form is filed and served upon the injured worker as notice of the employer’s intention to terminate or suspend compensation benefits. Any time benefits are temporarily suspended or are terminated, this form must be filed. The injured workers’ signature is required only when the injured worker disputes the termination or suspension of benefits and requests that the Board appoint an independent medical examination.

Form 29109: Application for Adjustment of Claim
This form is filed by either the injured worker or his employer in order to invoke the jurisdiction of the Board. The form may be filed by an injured worker who believes that he is entitled to compensation or medical benefits. An employer who believes that compensation should be terminated may also file the form.  This orm is also used to attempt to re-open a settled claim.

Form 1042: Application for Review by Full Board
This form is filed to invoke the jurisdiction of the full Board and must be filed within 30 days from the date of the Board’s decision. Filing this form is the first step in the process of appealing a claim.

Form 45422:Request for Assistance
This form is filed by the injured worker in order to involve an ombudsman in an attempt to formally resolve a dispute between the injured worker and his employer or the employer’s workers’ compensation insurance carrier.

Form 51247: Application for Second Injury Fund Benefits
This form is filed by an injured worker who has sustained a second injury to previously injured or amputated body parts, or who has exhausted all compensation benefits and remains disabled.

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