• California Claim 5 Ways and 5 Days to Report When reporting a new California workers' compensation claim, choose the method that works best for you.
• California Claim Form — Claims Kit for California Policyholders (Rev. 4-2024) Our online claims kit for California policyholders includes claim forms, posting notices, pamphlets, and other California workers’ compensation materials.
• California Claim Form — Employee DWC-1 (English - Spanish) (Rev. 1-1-2016) You are required to provide an injured worker with the DWC-1 Employee Claim Form with 24 hours of your knowledge of an alleged injury.
• California Claim Form — Employee DWC-1 and Factsheet (Korean) (Rev. 1-1-2016) Korean language version.
• California Claim Form — Employee DWC-1 and Factsheet (Tagalog) (Rev. 1-1-2016) Tagalog (Filipino) language version.
• California Claim Form — Employee DWC-1 and Factsheet (Vietnamese) (Rev. 1-1-2016) Vietnamese language version.
• California Claim Form — Employee Information Packet for Injured Worker (English) (Rev. 1-2024) MPN Notification of Rights, DWC Employee Factsheet, and Authorization for Medical Treatment also must be provided to an injured worker, along with the DWC-1 Employee Claim Form.
• California Claim Form — Employee Information Packet for Injured Worker (Spanish) (Rev. 1-2024) If needed, the Spanish version must be provided to an injured worker at the time of referral for initial medical care.
• California Claim Form — Employer 5020 (Rev. 6-2002) After completion, save this claim form to your computer. Submit this claim via email (riclaims@ri-net.com) or fax 818.789.7286 within 5-days of every industrial injury.
• California Medical Provider Network Frequently Asked Questions Describes our medical provider network (MPN) , explains the advantages and answers other questions regarding the network.
• California Pamphlet — DWC Time of Hire Pamphlet (English) (Rev. 2-2024) DWC Time of Hire Pamphlet must be provided to new employees at the time of hire. As an alternative, you may provide a printed copy of the “Facts About Workers’ Compensation” pamphlet.
• California Pamphlet — DWC Time of Hire Pamphlet (Spanish) (Rev. 7-2014) If needed, the Spanish version must be provided to new employees at the time of hire.
• California Posting Notice — Fraud Penalties Form 1002 (English - Spanish) (Rev. 3-2020) State-Mandated Fraud Penalties Posting Notice in English and Spanish.
• California Posting Notice — Injuries Caused By Work DWC-7 (English - Spanish) (Rev. 1-1-2016) Please input your Policy Effective Date, select the local I & A Office closest to your business, and display in a conspicuous location. As an alternative, you may post a printed copy of the “If A Work Injury Occurs…” Posting Notice.
• California Posting Notice — Instructions for Completion of DWC-7 (170-095) (Rev. 4-2022) Both English and Spanish versions of these state-mandated notices must be posted in a conspicuous location frequented by employees during the workday.
• California Posting Notice — When Medical Care is Needed SB559 (English - Spanish) (Rev. 4-2022) If you have not designated a Doctor/Clinic closest to your business, visit the MPN website at www.republicmpn.com or call 888-545-3795.
• California Supply Request Form (170-086A and B) (Rev. 4-2022) We have a variety of California workers’ compensation supplies that we can ship to you. Please submit your completed supply request form to our Mail/Supply Department via email at riclaims@ri-net.com or fax 818-382-1133.
Alaska Claim Form — Claims Kit for Alaska Policyholders (Rev. 7-2022) Our online claims kit for Alaska policyholders includes claim forms, posting notices, and other Alaska workers’ compensation materials.
Alaska Claim Form — Employee Authorization for Medical Treatment (170-367) (Rev. 3-2020) Authorization for Medical Treatment should be provided to an injured worker at the time of referral for initial medical care.
Alaska Claim Form — Employee Report of Injury 07-6100 (Rev. 4-1-2015) You are required to provide an injured worker with the 07-6100 Employee Claim Form immediately upon your knowledge of an alleged injury.
Alaska Claim Form — Employer Report of Occupational Injury 07-6101 (Rev. 2-2017) After completion, please save this claim form to your computer. Submit this claim via email to wcnewclaim@nadj.com or fax 907-868-3866 within 10 days of every industrial injury.
Alaska Posting Notice — Employer's Notice of Insurance 07-6120 (Rev. 5-2012) Please complete the state-mandated Employer’s Notice of Insurance and display in three conspicuous places on the employer’s premises.
Alaska Supply Request Form (170-409A and B) (Rev. 11-2020) We have Alaska workers’ compensation supplies that we can ship to you. Please submit your completed supply request form to our Mail/Supply Department via email at riclaims@ri-net.com or fax 818-382-1133.
Anti-Fraud Poster Magnifying Glass Version English For policyholders. Post in offices or facilities. Anti-fraud reminder in English. Size 8.5 x 11. Available in larger sizes: 11 x 17 and 18 x 24 inches. Contact our Loss Control Department at RICALC@ri-net.
Anti-Fraud Poster Magnifying Glass Version Spanish For policyholders. Post in offices or facilities. Anti-fraud reminder in Spanish. Size 8.5 x 11. Available in larger sizes: 11 x 17 and 18 x 24 inches. Contact our Loss Control Department at RICALC@ri-net.
Anti-Fraud Poster Pickpocket Version English For policyholders. Post in offices or facilities. Anti-fraud reminder in English. Size 8.5 x 11. Available in larger sizes: 11 x 17 and 18 x 24 inches. Contact our Loss Control Department at RICALC@ri-net.
Anti-Fraud Poster Pickpocket Version Spanish For policyholders. Post in offices or facilities. Anti-fraud reminder in Spanish. Size 8.5 x 11. Available in larger sizes: 11 x 17 and 18 x 24 inches. Contact our Loss Control Department at RICALC@ri-net.
Arizona Claim Form — Employee Authorization for Medical Treatment (170-367) (Rev. 3-2020) Authorization for Medical Treatment should be provided to an injured worker at the time of referral for initial medical care.
Arizona Claim Form — Employee ICA Injured Worker Handbook (Rev. 9-2020) Provides answers to common questions about industrial claims and workers’ compensation.
Arizona Claim Form — Employer Report of Industrial Injury ICA 0101 (Rev. 7-01-01) After completion, please save this claim form to your computer. Please submit this claim via email (riclaims@ri-net.com) or fax (602.912.9509) within 10-days of every industrial injury.
Arizona Claim Form — Preferred Provider Hospitals (170-259) (Rev. 6-2018) List of preferred provider hospitals in Arizona.
Arizona Claim Form — Preferred Provider Listing (170-260) (Rev. 6-2018) List of preferred provider medical facilities, urgent care centers, and clinics in Arizona.
Arizona Posting Notice — Notice to Employees (170-263) Arizona law requires employers to post a number of notices (or "posters"), and each notice must be posted in a conspicuous place where employees will see it.
Arizona Posting Notice — Work Exposure to Bodily Fluids ICA 04-615-01 Notice to employee, which includes instructions about filing a claim related to HIV, AIDs, or Hepatitis C.
Arizona Posting Notice — Work Exposure to MRSA (Rev. 7-11) Notice to employees (and instructions) about filing a claim for a condition, infection, disease, or disability related to MRSA.
Arizona Supply Request Form (170-266) (Rev. 11-2020) We have a variety of printed forms that we can ship to you. Please submit your completed supply request form to our Mail/Supply Department via email to riclaims@ri-net.com or fax 818-382-1133.
Colorado Claim Form — Designated Medical Providers List (Rev. 6-2022) A list of preferred provider medical facilities, urgent care centers, and clinics in Colorado.
Colorado Claim Form — Employee Authorization for Medical Treatment (170-367) (Rev. 3-2020) Authorization for Medical Treatment should be provided to an injured worker at the time of referral for initial medical care.
Colorado Claim Form — Employer First Report of Injury WC1 (Rev. 1-06) After completion, please save this claim form to your computer. Please submit this claim via email at riclaims@ri-net.com) or fax 602-912-9509 within 10-days of every industrial injury.
Colorado Claim Form — Employer Supplemental Report of Return to Work WC12 (Rev. 8-19) File a Supplemental Report of Return to Work form with the insurer each time the employee returns to work at full or reduced wages.
Colorado Supply Request Form (170-380) (Rev. 11-2020) We have a variety of printed forms that we can ship to you. Please submit your completed supply request form to our Mail/Supply Department via email at riclaims@ri-net.com or fax 818-382-1133.
Excess Comp Claim Form — Employer Initial Report (Rev. 11-2022) After completion, save this claim form to your computer. Please submit this claim via email to excesscomp@ri-net.com or fax 818-986-6559.
Idaho Claim Form — Employee Authorization for Medical Treatment (170-367) (Rev. 3-2020) Authorization for Medical Treatment should be provided to an injured worker at the time of referral for initial medical care.
Idaho Claim Form — Employer First Report of Injury or Illness IC Form IA-1 (Rev. 8-2013) After completion, save this claim form to your computer. Please submit this claim via email at riclaims@ri-net.com or fax 208-375-8905.
Idaho Claim Form — Employer Supplemental Report IC Form 14 File an Employer’s Supplemental Report form with the insurer upon an employee’s termination of disability or at the end of 60-days from the date disability began if the employee is disabled that long.
Idaho Supply Request Form 170-350 (Rev. 11-2020) We have a variety of printed forms that we can ship to you. Please submit your completed supply request form to our Mail/Supply Department via email at riclaims@ri-net.com or fax 818-382-1133.
Kansas Claim Form — Accident Report K-WC 1101-A (Rev. 10-13) After completion, save this claim form to your computer. Please submit this claim form within 28 days of the date the employer is informed of the accident via email to riclaims@ri-net.com or fax 702-796-1330.
Kansas Claim Form — Employee Authorization for Medical Treatment (170-367) (Rev. 3-2020) Authorization for Medical Treatment should be provided to an injured worker at the time of referral for initial medical care.
Kansas Pamphlet — Employee Notification Forms Available Online K-WC 530 (Rev. 10-13) Important Information for Employers Regarding Forms K-WC 27-A and K-WC 270-A (Spanish).
Kansas Pamphlet — Information for Injured Employees K-WC 270-A (Spanish) (Rev. 7-19) If needed, the Spanish version must be provided to an injured worker.
Kansas Pamphlet — Information for Injured Employees K-WC 27-A (English) (Rev. 7-19) Employers are required to provide this information to each injured worker.
Kansas Pamphlet — WC Information for Kansas Employers and Employees K-WC 25 (English) (Rev. 6-22) 20-page booklet on Kansas workers’ compensation benefits, employer guidelines, and other general information.
Kansas Posting Notice — Ombudsman Claims Advisory Services K-WC-P 101 (Rev. 6-12) The Ombudsman unit acts in an impartial manner and is available to provide the parties with general information about the current issues within the Kansas workers’ compensation system.
Kansas Posting Notice — WC Rights and Responsibilities K-WC 40-A (Rev. 3-18) This notice must be posted and maintained by the employer in one or more conspicuous places.
Kansas Supply Request Form (170-423) (Rev. 11-2020) We have a variety of printed forms that we can ship to you. Please submit your completed supply request form to our Mail/Supply Department via email to riclaims@ri-net.com or fax 818-382-1133.
Missouri Claim Form — Employee Authorization for Medical Treatment (170-367) (Rev. 3-2020) Authorization for Medical Treatment should be provided to an injured worker at the time of referral for initial medical care.
Missouri Claim Form — Employer Report of Injury WC-1-EDI (Rev. 02-16) After completion, save this claim form to your computer. Please submit this claim form within 5 days of the date the employer is informed of the accident via email to riclaims@ri-net.com or fax 702-796-1330.
Missouri Pamphlet — Facts for Injured Workers WC-101 (English) (Rev. 05-21) 12-page pamphlet with information about Missouri workers’ compensation.
Missouri Posting Notice — Workers' Compensation Law WC-106 (English) (Rev. 07-19) Employers are required to post this notice in the workplace for employees to view.
Missouri Supply Request Form (170-328) (Rev. 11-2020) We have a variety of printed forms that we can ship to you. Please submit your completed supply request form to our Mail/Supply Department via email to riclaims@ri-net.com or fax 818-382-1133.
Montana Claim Form — Employee Authorization for Medical Treatment (170-367) (Rev. 3-2020) Authorization for Medical Treatment should be provided to an injured worker at the time of referral for initial medical care.
Montana Claim Form — First Report of Injury or Occupational Disease ERD-991 (Rev. 05-2016) Montana law requires employers to complete this form within six days after notice of every on-the-job accident, injury and/or occupational disease (OD) by a worker. The worker and employer may complete this form together or submit it separately.
Montana Supply Request Form (170-238) (Rev. 11-2020) We have a variety of printed forms that we can ship to you. Please submit your completed supply request form to our Mail/Supply Department via email to riclaims@ri-net.com or fax 818-382-1133.
Nevada Claim Form — Employee Authorization for Medical Treatment (170-367) (Rev. 3-2020) Authorization for Medical Treatment should be provided to an injured worker at the time of referral for initial medical care.
Nevada Claim Form — Employee Notice of Injury C-1 (Rev. 2-20) You are required to provide an injured worker with the C-1 Employee Notice of Injury Form upon your knowledge of an alleged injury.
Nevada Claim Form — Employer Report of Industrial Injury C-3 (Rev. 2-20) After completion, save this claim form to your computer. Please submit this claim via email to riclaims@ri-net.com or fax 702-796-1330.
Nevada Posting Notice — Brief Description of Your Rights and Benefits D-1 (English) (Rev. 2-24) Nevada law requires employers to post a number of notices (or "posters"), and each notice must be prominently displayed in your place of business.
Nevada Posting Notice — Brief Description of Your Rights and Benefits D-2 (English) (Rev. 2-24) Nevada law requires employers to post a number of notices (or "posters"), and each notice must be prominently displayed in your place of business.
Nevada Posting Notice — Notice to Employees D-22 (Rev. 7-99) Notice and instruction to employees regarding the reporting of tips received.
Nevada Supply Request Form (170-434) (Rev. 12-2020) We have a variety of printed claim forms that we can ship to you. Please submit your completed supply request form to our Mail/Supply Department via email at riclaims@ri-net.com or fax 818-382-1133.
New Mexico — Employee Authorization for Medical Treatment (170-367) (Rev. 3-2020) Authorization for Medical Treatment should be provided to an injured worker at the time of referral for initial medical care.
New Mexico Claim Form — Employers' First Report of Injury or Illness E1.2 (Rev. 7-02) This form must be filed within 10 days of knowledge of any alleged work-related injury or illness that results in more than 7 days of lost work.
New Mexico Claim Form — Notice of Accident or Occupational Disease Disablement NOA-1 (English - Spanish) (Rev. 11-18) In most cases, an employee must tell their employer about the accident within 15 days using the Notice of Accident Form.
New Mexico Posting Notice — Workers' Compensation Act (English - Spanish) (Rev. 11-18) You are required by law to display this poster where your employees can read it. Post the Notice of Accident forms with it. The poster without the Notice of Accident forms does not comply with law.
New Mexico Supply Request Form (170-058) (Rev. 11-2020) We have a variety of printed forms that we can ship to you. Please submit your completed supply request form to our Mail/Supply Department via email to riclaims@ri-net.com or fax 818-382-1133.
Oregon Claim Form — Employee and Employer Report of Job Injury 440-801 (English) (Rev. 1-2021) After completion, scan this claim form to your computer. Please submit this claim via email at riclaims@ri-net.com or fax 503-626-7105.
Oregon Claim Form — Employee Authorization for Medical Treatment (170-367) (Rev. 3-2020) Authorization for Medical Treatment should be provided to an injured worker at the time of referral for initial medical care.
Oregon Claim Form — Employee Guide for Workers Recently Hurt on the Job 440-3283 (English) (Rev. 1-2021) A Guide for Workers Recently Hurt on the Job given to the worker by the employer at the time a worker files a claim for workers’ compensation benefits.
Oregon Claim Form — Employee Guide for Workers Recently Hurt on the Job 440-3283s (Spanish) (Rev. 1-2021)
Oregon Supply Request Form (170-318) (Rev. 11-2020) We have a variety of printed claim forms that we can ship to you. Please submit your completed supply request form to our Mail/Supply Department via email at riclaims@ri-net.com or fax 818-382-1133.
Texas Claim Form — Employee Authorization for Medical Treatment (170-367) (Rev. 3-2020) Authorization for Medical Treatment should be provided to an injured worker at the time of referral for initial medical care.
Texas Claim Form — Employee DWC Notice of Injured Employee Rights (English) (Rev. 6-2012) You are required to provide an injured worker with the Notice of Injured Employee Rights and Responsibilities in the Texas Workers’ Compensation System upon your knowledge of an alleged injury.
Texas Claim Form — Employer First Report of Injury DWC Form-001 (Rev. 10-05) After completion, save this claim form to your computer. Please submit this claim via email to riclaims@ri-net.com or fax 800.275.3194.
Texas Posting Notice — Notice of Ombudsman (English - Spanish) (3-10) Texas law requires employers to post a number of notices (or "posters"), and each notice must be posted for employees to read.
Texas Posting Notice — Notice to Employees Notice 6S (Spanish) (01-13) Required notice to employees that you have workers' compensation coverage. Spanish version.
Texas Posting Notice — Notice to New Employee (English) (01-13) A notice to new employees stating that you have workers' compensation coverage.
Texas Supply Request Form (170-612) (Rev. 11-2020) We have a variety of printed forms and notices that we can ship to you. Please submit your completed supply request form to our Mail/Supply Department via email at riclaims@ri-net.com or fax 818-382-1133.
Utah Claim Form — Employee Authorization for Medical Treatment (170-367) (Rev. 3-2020) Authorization for Medical Treatment should be provided to an injured worker at the time of referral for initial medical care.
Utah Claim Form — Employee Guide to Workers' Compensation (English) (2015 - 2016) The Industrial Accidents Division of the Utah Labor Commission has prepared this pamphlet to answer questions employees often ask about workers’ compensation benefits.
Utah Claim Form — Employer First Report of Injury Form 122E (Rev. 10-2019) After completion, save this claim form to your computer. Please submit this claim via email to riclaims@ri-net.com or fax 801-466-1749.
Utah Claim Form — Employer Guide to Workers' Compensation (2015 - 2016) This Employers’ Guide to Workers’ Compensation will help Utah employers understand the basic requirements of the workers’ compensation system.
Utah Posting Notice — OSHA Poster (English) (Rev. 11-03-14) The Utah Labor Commission requires that employers post the following notices (or "posters") at your place of business.
Utah Supply Request Form (170-698) (Rev. 11-2020) We have a variety of printed Utah workers’ compensation supplies that we can ship to you. Please submit your completed supply request form to our Mail/Supply Department via email at riclaims@ri-net.com or fax 818.382.1133.
• California Claim Form — Employee DWC-1 and Factsheet (Chinese) (Rev. 1-1-2016) For your convenience, we also provide the DWC-1 Employee Claim Form and DWC Employee Factsheet in Chinese and other languages.