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Workers Compensation for West Virginia

  • Adjustment/correction Request
    File .pdf (63.7 Kbytes)
  • Application For Coverage, West Virginia Coal-workers Pneumoconiosis Fund (form In
    File .doc (35.5 Kbytes)
  • Application For Dependents` Benefits
    File .pdf (128 Kbytes)
  • Application For Extraterritorial Coverage
    File .pdf (37 Kbytes)
  • Application For Independent Medical Examiner
    File .doc (49 Kbytes)
  • Application For Permanent Total Disability Award
    File .pdf (96.8 Kbytes)
  • Attending Physician`s Report
    File .pdf (13.7 Kbytes)
  • Claim Reopening Application
    File .pdf (112.8 Kbytes)
  • Claimant Travel Voucher (form In
    File .doc (37 Kbytes)
  • Diagnosis Update
    File .pdf (27.6 Kbytes)
  • Direct Deposit Authorization (form In
    File .doc (25.5 Kbytes)
  • Employers Assessment Of Rehabilitation Needs
    File .pdf (29.6 Kbytes)
  • Employers Excess Liability Fund Application
    File .pdf (108.5 Kbytes)
  • Employers Report Of Occupational Pneumoconiosis
    File .pdf (60.1 Kbytes)
  • Employer`s Proposal For Alternate/modified Job Duties
    File .pdf (77.5 Kbytes)
  • Employer`s Response To Petition For Lump-sum Settlement
    File .pdf (25 Kbytes)
  • Independent Medical Examiner (ime) Fee Schedule
    File .doc (28 Kbytes)
  • Information On Extraterritorial Coverage
    File .pdf (53.5 Kbytes)
  • Instructions For Claimant Travel Voucher
    File .doc (37 Kbytes)
  • Irrevocable Letter Of Credit
    File .doc (29.5 Kbytes)
  • Notice To Be Posted By All Employers In Default
    File .pdf (880.8 Kbytes)
  • Notice To Employers
    File .pdf (21.9 Kbytes)
  • Pharmacy Invoice
    File .doc (79.5 Kbytes)
  • Pharmacy Invoice (coal Workers Pneumoconiosis Fund)
    File .doc (79.5 Kbytes)
  • Physicians Report Of Occupational Pneumoconiosis
    File .pdf (50.2 Kbytes)
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