Indiana Workers Compensation - Official forms

Workers Compensation - Official - General

• Agreement to Compensation - SF 1043 IN-1043-WC
• Application for Adjustment of Claim - SF 29109 IN-29109-WC
• Request for Assistance - SF 45442 IN-45442-WC
• Application for Worker's Compensation Clearance Certificate (English) - SF 45899 IN-45899-WC

Workers Compensation - Official - Injury

• First Report of Injury - SF 34401 IN-34401-WC

Workers Compensation - Official - Reports

• Report of Temporary Total Disability (TTD)/Temporary Partial Disability (TPD) Termination/Reduction - SF 38911** IN-38911-WC

Workers Compensation - Official - Reviews

• Application for Review by Full Board - SF 1042 IN-1042-WC