| Form # | Description | DOC | Filing Fee | |
|---|---|---|---|---|
| 12A |
First Report of Injury |
Doc | No fee | |
| 12M | Annual Minor Medical Report | Doc | No fee | |
| 14A | Health Insurance Claim Form | Doc Format Not Available |
No fee | |
| 15 | Temporary Compensation Report | Doc | $50.00 for Section III only | |
| 15S | Supplemental Report of Varying Temporary Partial Payments | Doc | No fee | |
| 16 | Agreement for Permanent Disability / Disfigurement Compensation | Doc | $50.00 if Claimant is represented | |
| 16A |
Agreement for Permanent Disability / Disfigurement Compensation Please complete this form for injuries occurring after July 1, 2007. |
Doc |
$50.00 if Claimant is represented |
|
| 17 |
Receipt of Compensation |
Doc | No fee | |
| 18 | Periodic Report | Doc | No fee | |
| 19 | Status Report and Compensation Receipt | Doc | No fee | |
| 20 | Statement of Earning of Injured Employee | Doc | No fee | |
| S-1 |
Notice of Third Party Action Employee Carrier |
Doc | No fee | |
| S-3 |
Entitlement to Right of Action |
Doc | No fee | |
| S-4 |
Court Certificate |
Doc | No fee |
Advisory: Updated Richland Hearing Notice for July and August. The full advisory may be found here.
Effective July 1, 2026, the 2026 standard mileage compensation rate has been increased to 76 cents per mile. The full advisory may be accessed here.