Insurers

The injured worker must file a COLA Request Form every year in order to apply for the applicable cost of living adjustments.

This form is to be completed by the claim administrator whenever a claim has been accepted as compensable and the injured worker is entitled to an award. This Award Agreement provides the basis for the award of compensation and contains sufficient information to establish the essential elements of a compensable claim. For subsequent periods of compensation benefits, this form should be used each time the injured worker’s wage loss period and compensation rate differ.

The treating physician completes this form and the report provides specific medical information including date of accident, diagnosis, prognosis, the disability period(s), and the extent of any permanent disability. This form must be signed by the treating physician.

In cases of amputation for hand/foot, the treating physician completes this form and may fill out the Amputation Chart.