Form Title |
Form Number |
Date Revised |
Purpose |
Instructions |
PDF |
Excel |
Coordination of Retirement Benefits |
DWC-36 |
04/05 |
|
|
|
Not available |
Employee's Certificate of Dependency Status |
DWC-04 |
01/03 |
|
|
|
Not available |
Employee's Objection to Wage Transcript |
DWC-31 |
01/03 |
|
|
|
Not available |
Employer's First Report of Alleged Occupational Injury or Disease |
DWC-01 |
01/03 |
|
|
|
DWC-01 |
Insurance Coverage Certification for Temporary Employment and Employee Leasing Companies |
DWC-09 |
11/05 |
|
Not available |
|
Not available |
Insurer Assessment Return |
----- |
02/10 |
|
|
|
Not available |
Itemized Statement of Compensation |
DWC-50 |
01/03 |
|
|
|
Not available |
Memorandum of Agreement |
DWC-02 |
01/03 |
|
|
|
Not available |
Mutual Agreement |
DWC-24 |
01/03 |
|
|
|
Not available |
Non-Prejudicial Agreement |
DWC-20 |
01/03 |
|
|
|
Not available |
Notice to Employees Regarding Benefit Check |
DWC-32 |
01/03 |
|
Not available |
|
Not available |
Report of Earnings |
DWC-25 |
01/03 |
|
|
|
Not available |
Report of Indemnity Payment |
DWC-22 |
01/03 |
|
|
|
Not available |
Report of Payment Supplement |
DWC-22a |
OBSOLETE |
|
Use
DWC-22 |
Not available |
Not available |
Report of Specific Payment |
DWC-51 |
01/03 |
|
|
|
Not available |
Suspension Agreement and Receipt |
DWC-05 |
01/03 |
|
|
|
Not available |
Termination of Benefits |
DWC-21 |
OBSOLETE |
|
Use
DWC-22 |
Not available |
Not available |
Wage Statement: Full Time |
DWC-03F |
01/03 |
|
Instructions | Tips |
|
DWC-03F |
Wage Statement: Part Time |
DWC-03P |
01/03 |
|
|
|
DWC-03P |
Wage Statement: Seasonal |
DWC-03S |
01/03 |
|
|
|
DWC-03S |
Wage Transcript |
DWC-30 |
01/03 |
|
|
|
Not available |
