Claim forms for your reference
Please click on the following forms to download or print.
CALL YOUR WCTI CLAIM REP WHEN...
CLAIMS CHECKLIST
CONTROLLING WORKERS' COMPENSATION COSTS
DUTY STATUS REPORT
EMPLOYEE'S INJURY REPORT
ERGO CUM TRAUMA QUESTIONNAIRE
MEDICAL AUTHORIZATION FORM
MINOR INJURY REPORT
STATE OF IL NOTICE TO EMPLOYEES
SUPERVISOR'S INJURY REPORT
TRANSMITTAL FORM
WAGE STATEMENT
WCTI CLAIMS PROCEDURES
WCTI FORM 45
WHAT TO DO IN THE EVENT OF A WORKERS' COMP CLAIM
WITNESS STATEMENT
WORKERS' COMPENSATION CLAIMS GUIDELINES
If you have any questions or would like an updated claim packet, please contact Gina Reynolds at 800.628.5618, ext 6004.
Please click on the following forms to download or print.
CALL YOUR WCTI CLAIM REP WHEN...
CLAIMS CHECKLIST
CONTROLLING WORKERS' COMPENSATION COSTS
DUTY STATUS REPORT
EMPLOYEE'S INJURY REPORT
ERGO CUM TRAUMA QUESTIONNAIRE
MEDICAL AUTHORIZATION FORM
MINOR INJURY REPORT
STATE OF IL NOTICE TO EMPLOYEES
SUPERVISOR'S INJURY REPORT
TRANSMITTAL FORM
WAGE STATEMENT
WCTI CLAIMS PROCEDURES
WCTI FORM 45
WHAT TO DO IN THE EVENT OF A WORKERS' COMP CLAIM
WITNESS STATEMENT
WORKERS' COMPENSATION CLAIMS GUIDELINES
Benefits of WCTI Membership:
- Ownership
- Loss Prevention
- Aggressive Claims Management
- Managed Care Program
- Prescription Drug Program
- Prompt Reporting
Need more information?
If you would like additional information on this successful program, please contact Angie Blakeney at 800.252.5059, ext. 1117 or e-mail Angie at ablakeney@ccmsi.com.