Form Changes—Effective February 15, 2016

There are a total of 11 forms that have been created or amended to conform to the new ICMS II system. The following is a list of the amended forms and an explanation of the changes.

WC-6 – Wage Statement
This form has been amended to add another box in section C for “no off days.”

WC-14- Notice of Claim/Request for Hearing/Request for Mediation
This form has been amended to add a box for description of accident, dependency benefits and burial expenses. The form has also been changed so that the insurer information no longer includes the claims office when an initial WC-14 is filed. The claims office will be added by the filing of a WC-1. “Multiple body parts” has been removed as a selection for “Part of Body Injured,” and more than one body part may now be selected.

WC-14a-Request to Change Information on a Previously Filed WC-14
This form has been amended to allow information previously filed on a WC-14 to be corrected. The following information can be changed on this form: the date of injury (plus or minus 30 days from the date of injury on the WC-14), correction of a party name, dismissal of an employer, insurer/self-insured employer or claims office. Hearing issues may also be added on this form.

WC-20a – Medical Report
This form has been amended to update the box in number 6 from ICD-9 code to ICD-10 code.

WC-25 – Application for Lump Sum/Advance Payment
This form has been streamlined and made more user-friendly. Sections B thru F have been changed to provide for better organization of the information requested.

WC-100 – Request for Settlement Mediation
This form was amended to remove the former Section B – “Settlement Request information,” and make Section B the “Certification” section.

WC – Request To Change Information – New form
This form was created to correct the employee’s name, SSN or Board Tracking #, correct the county of injury and to correct a claims office that has been listed incorrectly in the claim.

WC-Change of Address
This form was amended to allow the filing of the form online to correct the address of the employee/claimant, employer, attorney, and other party – insurer, self-insurer, claims office and party at interest.

Request for Rehabilitation-This form was amended to remove the catastrophic injury box in Section 1.

This form was amended to add “prior to injury” after 15 years in Section 3.

WC-Rehab Objection
This form was amended to change the order of the boxes listed in Section B to the following:
1. WC-R1
3. WC-R2
4. WC-R2a
5. WC-R3