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West Virginia Form Center

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		WEST VIRGINIA INSURANCE COMMISSION FORMS
		(OIC-WC-1) Employees’ and Physicians’ Report of Occupational Injury or Disease - N/D
		(OIC-WC-1HL) Employees’ and Physicians’ Report of Occupational Hearing Loss - N/D
		(OIC-WC-10P) Employees\' Report of Occupational Pneumoconiosis - N/D
		(OIC-WC-2) Employers’ Report of Occupational Injury or Disease - N/D
		(OIC-WC-201) Application for Fatal Dependents’ Benefits - N/D
		(OIC-WC-202) Application for 104 Weeks Dependents’ Benefits - N/D
		(claims-allocation-information) Notification Regarding Claims Allocation - 1/06
		(wc complaint form) Workers’ Compensation Complaint Form - 1/08
		(exemption-application) Application for Exemption from WV Workers’ Compensation Coverage - 9/08
		(microfiche) Request For File Copies - 10/08
		(occ-lung-exam) Carrier's Request For Occupational Lung Center Examination - 8/07
		(complaint-form) Workers’ Self-Insurance Compensation Complaint Form - N/D
		(term-cov) Termination Of Coverage - 3/08
		(travel-expense-notice) Payment for Travel Expenses Notice - 1/06
		(UninsuredFundApplication) Employee’s Report of Occupational Injury and Proof of Employment - 1/06

		BRICKSTREET FORMS
		(BI-309) Return to Work Notice - 1/06
		(BI-1) Employees' and Physicians' Report of Injury - 1/06
		(BI-3) Employer's Report of Injury - 9/07
		(BI-402104) Application for 104 Weeks Dependents' Benefits - 1/06
		(BI-bl1) Application for Coverage under Coal-Workers' Pneumoconiosis Fund - 1/06
		(BI-402) Application for Fatal Dependents' Benefits - 1/06
		(BI-115) Application for Permanent Total Disability Benefits - 1/06
		(BI-1HL) Employee and Physician's Report of Occupational Hearing Loss - 1/06
		(BI-1HLa) Employee and Physician's Report of Occupational Hearing Loss (Non-Occupational Noise) - 1/06
		(BI-105) Employees' Report of Occupational Pneumoconiosis - 1/06
		(BI-3od) Employer's Report of Occupational Disease - 1/06
		(BI-3HL) Employer's Report of Occupational Hearing Loss - 9/07
		(BI-305) Employer's Report of Occupational Pneumoconiosis - 1/06
		(BI-125) Claim Re-opening Application for Temporary Total Disability/Wage Replacement Benefits - 4/07
		(BI-125 app) Application for Temporary Total Disability / Wage Replacement or Medical Treatment - 1/06
		(BI-126 re-opening) Claims Re-opening Application for Permanent Partial Disability - 1/06
		Instructions for Completing Settlement Application - 1/06
		(BI-219) Attending Physician's Report - 1/06
		(BI-219a) Notice of Maximum Medical Improvement - 1/06
		(BI-401) Pharmacy Invoice - 1/06
		(BI-205) Physician's Report of Occupational Pneumoconiosis - 1/06
		(BI-206) Physician's Roentgenographic Interpretation Report of Occupational Pneumoconiosis - 1/06
		(BI-rcp) Request for Change of Physician - 1/06
		(BI-910) Request for File Copies - 1/06
		(BI-rpd) Request to Protest Decision - 1/06
		(BI-jaf) Job Analysis Form - 1/06
		(BI-214) Diagnosis Update - 1/06
		(BI-can) Change of Address Notification - 1/06
		(BI-102) Claimant Travel Voucher - 4/07
		(BI-105) Employees Report of Occupational Pneumoconiosis - 9/07
		(BI-ClsrRpt) Rehabilitation Closure Report - 10/07
		(BI-RhbPln) Rehabilitation Plan - 1/07
		(BI-RhbStmt) Vocational Rehabilitation Disclosure Statement - N/D
		(BI-WAGE) Employer's Report of Wages - 5/07
		(Authorization) Authorization for Use and Disclosure of Personal Financial and Health Information - 5/08
		(BI-MCPGF) Grievance Form - 1/09

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