Benefit
Forms: Disability/Workers' Compensation
Disability Forms:
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Disability - Agency Disability Questionnaire
This form is to be completed by the employer and should accompany all initial mental health-related disability claims being filed with DAS-Benefits Administrative Services-Disability.
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This form is to be completed by the attending physician for use in transitional return to work. This may be used for either Workers' Compensation or Disability.
Workers' Compensation Forms:
- Work
Capacity Form (ADM 4317)
This form is to be completed by the attending physician for use in transitional return to work. This may be used for either Workers' Compensation or Disability.
Occupational Injury Leave
The following three forms are to be completed and sent to the third party administrator by the employing agency for an initial request for OIL benefits.
Occupational Injury Leave - Extension of Benefits
The following three forms are to be completed and sent to the third party administrator when an extension of OIL benefits is being requested.
PLEASE
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If you are unsure of which category your form falls into, click here for an alphabetized list of all available forms. |
