Documents for Employers
|Lapsed Coverage Forgiveness Form
The following BWC form can be used for the one-time forgiveness program for lapsed coverage.
|AC-2 Permanent Authorization
The AC-2 is used to make a permanent assignment of an authorized representative to handle risk and claim issues on behalf of an employer.
|PDF | Web|
|AC-3 Temporary Authorization to Review Information
The AC-3 provides a limited authorization for the TPA to review an employer’s risk and claim files, experience data, and other associated information.
|PDF | Web|
|C-55 Salary Continuation Agreement
This form is used to acknowledge an agreement to pay salary/wage continuation in lieu of temporary total or living maintenance compensation.
| Notification of Business Acquisition/Merger or Purchase/Sale
An employer must complete the U-118 when succeeding another business in whole or in part for the purposes of transferring experience.
|Transitional Work Bonus Program Application
This form is used to apply for a bonus of up to 10% of employer’s pure premium based on the success of the transitional work program utilized on eligible claims with dates of injury within enrolled bonus period.