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Forms and Guides


Guides

Guide for the Injured Worker - NEW


Forms

For the convenience of our customers, IWIF has built a listing of downloadable PDF forms that you can print as needed. Each of the forms listed includes a brief description of what the form is to be used for. Some are available in Spanish.

PRIMARY: Accident Investigation/Reporting and Injured Worker Forms

Accident Investigation Forms - English - PDF

Accident Investigation Forms - Spanish - PDF

The injured employee, supervisor and any witnesses to the accident should complete and sign these forms. Keep a copy of the completed forms for your records. The completed forms should then be mailed or faxed to your IWIF Claims Adjuster. Obtaining signed statements as soon as possible following an accident ensures that you, the employer, have an accurate account of how the injury occurred.

ACORD 4 First Report of Injury (FROI) PDF

(Important) We strongly recommend employers report the injury via our toll-free injury reporting hotline or using our online injury reporting service. Reporting the injury via our hotline or using our online injury reporting service is more convenient and faster than manually completing the form. If you choose to manually complete the Employer's First Report of Injury form, please submit the completed form either by FAX to 410-494-2002 or send by mail to: IWIF, 8722 Loch Raven Boulevard, Towson, MD 21286.

Temporary Prescription Services ID Form PDF

When an employee requires medical treatment and needs prescriptions filled for a work-related injury, provide the employee with a copy of this form to take to the pharmacy. When this completed form is presented to the participating pharmacy, the prescriptions are filled with no out-of-pocket expenses for the employee.

Wage Statement Form PDF

A form used to list the gross weekly earnings paid to the injured worker for the 14 weeks immediately prior to the date/week of the accident for the purpose of calculating benefits.

When an Injury Occurs Flyer - English - PDF

A one-page, step-by-step reminder guide for reporting an injury immediately and for obtaining medical care. Please fill in the medical provider's name of your choice on the flyer. Please copy the reminder flyer as needed and distribute or post for supervisory staff. Spanish Form - PDF

SECONDARY: Accident Reporting and Injured Worker/Claimant Forms


Medical Travel Expense Form PDF

Claimants are entitled to reimbursement for travel expenses for medical treatment resulting from a work injury. This completed form, along with appropriate receipts, is required for reimbursement.

Other Forms


Accident Leave Request Form

Accident Leave Update Form

Return To Work Capacity Form

Job Analysis Form for Return to Work Program PDF

All "jobs/positions" in your business should have a job analysis form completed and on file. The information on this form is valuable in helping the claims adjuster and treating physician better understand the job duties and physical demands of an injured worker. This form is especially important for determining a temporary modified job function for the employee.

Physicians Evaluation Form for Return to Work Program PDF

A one-page form for the injured workers' treating physician to complete, detailing the physical limitations of the injured employee. This is a helpful tool for identifying a suitable temporary modified job.

Workers' Compensation Commission Forms

IWIF State of MarylandSafety University

Injured Workers' Insurance Fund • 8722 Loch Raven Blvd. • Towson, MD 21286   410-494-2000  1-800-264-4943   Privacy Policy and Data Security