Common Claim Forms

Employer Forms

C-107

Reimbursement request for any wages paid to the injured worker after the injury or illness occurs (if no reimbursement is requested please indicate so on the form).
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First Report of Injury/Illness

File electronic first reports of injury or illness using SIF eFroi system. Only the employer should complete this electronic document.
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Recommendation of Care Provider Network

Recommendation of Care Provider Network Link
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Prescription Card

A temporary card your employee can use following an injury.
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C-11

Completed as soon as employment status of injured employee changes.
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Pharmacy Network

Pharmacy Network Link
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C-240

C-240 Payroll Information.
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Injury Worker Forms

Claimant Packet (English)

General information on the claim process. This packet should be given or mailed to the injured worker following the injury.
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Claimant Packet (Spanish)

General information on the claim process. This packet should be given or mailed to the injured worker following the injury. Spanish.
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Early Returns to Work Forms

Job Demand Summary

If you have a position in mind and you would like the treating doctor to consider releasing the employee please complete the attached form and email or fax to the KSW claims team.
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Claim Management System

Connects

CONNECTS is a powerful claims management tool you can register for to access your claims information.
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Doctor Forms

C-4

This form is filed within 48 hours of first treatment by the treating doctor. This form is needed to initiate payment to the injured worker. To report continued treatment, use Form C-4.2. To report permanent impairment use Form C-4.3.
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