The Workers’ Compensation forms below, in either Word or PDF formats, are for the use of JPA members only.
Select the form you would like to download or print.
Certificate of Insurance Request
Company Nurse Flyer
Employee Predesignated Treating Physician Notification
Log for Dispensing Employee Claim form (DWC 1)
Notice of Employee Death
Physician Consent to Preform Employment Test
Physician Consent to Preform Fit for Duty Test
Supervisor’s Report of Employee Injury
Work Status Report