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New Hampshire Form Center

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		(8wc) Employer's First Report of Occupational Injury or Disease Form - 7/95
		(8awca) Notice of Accidental Injury Or Occupational Disease - 8/01
		(9wca) Memo of Payment of Disability Compensation - 6/94
		(9wca1) Memo of Denial of Workers' Compensation Benefits - 9/02
		(9wca2) Application for Reimbursement of Paid Adjusted Total Disability - 9/94
		(10wca) Memo of Permanent Impairment Award - 10/98
		(13wca) Employer's Supplemental Report of Injury - 7/89
		(14wca) Authorization for Compensation for Death - 10/01
		(15wca) Lump Sum Settlement Forms - 10/99
		(wc3pr1) Release and Settlement of Claim - 7/89
		(74wca) Report of Extended Disability - 7/89
		(75wca1) NH Workers' Compensation Medical Form - 6/94
		(76wca) Wage Schedule - 1/94
		(76wca1) Supplemental Wage Schedule Las- N/D
		(53wc) Employee's Statement of Employment Status - 12/00
		(53a) Notice to Suspend Payment of Workers' Compensation Benefits - 12/00
		(elpi) Parent Company Agreement - N/D
		(gp) Guarantee Proposal - 1/92
		(ol) Outstanding Liabilities - 3/75
		(sda) Securities Deposit Agreement - 1/92
		(si-q) Self-Insurance Questionnaire - N/D
		(si1) Self-Insurance Application - 1/92
		(si2) Self-Insurance Surety Bond - 8/94
		(si2a) General Purpose Rider - 8/94
		(si4) Certificate of Insurance - 1/92
		(si11) Annual Financial Statement - 3/75
		(si-e) Endorsement - 4/96
		(sif1) Application for Second Injury Fund - 9/98
		(sif1a) Second Injury Fund Affidavit of Employer Knowledge - 9/98
		(sif1b) Second Injury Fund Certification by Physician - 12/96
		(SIF-Request) Request for Reimbursement from the Second Injury Fund - 8/08
		(SIF-Schedule) Schedule of Reimbursable Payments - 8/08
		(taxa) NH Workers' Compensation Task Analysis - N/D
		(wctpa) Security Deposit Agreement for Third Party Administrator - 11/95
		(tpab) Third Party Administration Bond - N/D
		(bioa) Biographical Affidavit - N/D
		(coa) Application for Certificate of Authority - 12/95
		(noc) Notice of Contract Between Third Party Administrator and Self Insurer - N/D
		(vr1) Vocational Rehabilitation Provider Certification Form - 1/97
		(iwrp) Individual Written Rehabilitation Plan - N/D
		(vrt) Vocational Rehabilitation Training Agreement - N/D
		(jobmod) Request for Job Modification Plan Approval - N/D
		(Criteria) Criteria to Establish an Employee or Independent Contractor - 1/08
		(RehabClosure) Rehabilitation Closure Form - N/D
		(RehabReferral) Rehabilitation Referral Form - N/D

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