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This form is needed to properly compute the wage for your Worker's Compensation benefits. What you get: Instant access to fillable Microsoft Word or PDF forms.Minimize the risk of using outdated forms and eliminate rejected fillings. (Please read the instructions on page 2 for completing this form). These are called "work restrictions. Employers may also have the option to self-insure for workers' compensation. How do I get placed on the self-exclusion list? Can I just mail back the completed application? Limiting beliefs are any selfdeprecating thoughts that hold you back from growing as a person. O Have been awarded permanent and total disability.