Workers' Compensation FormsThe Workers’ Compensation forms below are for JPA members only. Select the form you would like to download or print. d Designated Hospitals and Clinic Providers h DWC 1 Form (fillable pdf) o Employee Predesignated Treating Physician Notification o Employee - Supervisor Incident Report i Form 5020 (fillable pdf) a Log for Dispensing Employee DWC1 Claim Form (Excel Spreadsheet) j Medical Release j Medical Mileage Reimbursement Form (doc) Notice of Employee Death (fillable pdf) Notice to Employees-Injuries Caused by Work Z Physician Consent to Perform Employment Test b Physician Consent to Perform Fit for Duty Test f Pre-Employment Physical Supervisor's Report of Employee Injury (fillable pdf) Time of Hire - Workers' Compensation Pamphlet
