Forms Library
Access A.I.M. Mutual Forms & Related Documents
For injury reporting, start with Report an Injury. From there, you can access the secure claim reporting form and select the state where the injury occurred.
Claim Forms by State
Workers’ compensation claim forms vary by state.
Select the state where the injury occurred and use the forms listed for that state.
Massachusetts Claim Forms
Claim Kit - MA
Forms and guidance for Massachusetts workplace injury claims.
Download Claim Kit - MA (opens in a new tab)
Employer’s First Report of Injury or Fatality, Form 101
Use if reporting a Massachusetts claim by fax.
Download Employer’s First Report of Injury or Fatality, Form 101 (opens in a new tab)Industry Reference Code, Form 101
Find the correct industry code for Form 101.
Download Industry Reference Code, Form 101 (opens in a new tab)Average Weekly Wage Computation Schedule, Form 127
Calculate and report an injured worker’s average weekly wage.
Download Average Weekly Wage Computation Schedule, Form 127 (opens in a new tab)Request for Medical Services
Request medical services related to a workers’ compensation claim.
Download Request for Medical Services (opens in a new tab)Medical Release for Injured Workers, MA
Authorize release of medical information for a claim.
Download Medical Release for Injured Workers, MA (opens in a new tab)Med-Fax Report
Report Massachusetts medical-only claims. Do not submit to the Department of Industrial Accidents.
Download Med-Fax Report (opens in a new tab)A.I.M. Vantage Occupational Health Urgent Care Centers
Find occupational health urgent care center information for workplace injury care.
Download A.I.M. Vantage Occupational Health Urgent Care Centers (opens in a new tab)New Hampshire Claim Forms
Claim Kit - NH
Forms and guidance for New Hampshire workplace injury claims.
Download Claim Kit - NH (opens in a new tab)Notice of Accidental Injury or Occupational Disease, Form 8aWCA
Document notice of an injury or occupational disease.
Download Notice of Accidental Injury or Occupational Disease, Form 8aWCA (opens in a new tab)Employer’s First Report of Occupational Injury or Disease, 8WC
Use if reporting a New Hampshire claim by fax.
Download Employer’s First Report of Occupational Injury or Disease, 8WC (opens in a new tab)Employer’s Supplemental Report of Injury, 13WCA
Provide updated information for an existing claim.
Download Employer’s Supplemental Report of Injury, 13WCA (opens in a new tab)Wage Schedule, 76 WCA
Report wage information for a claim.
Download Wage Schedule, 76 WCA (opens in a new tab)Supplemental Employee Forms - Lost Time Only
Provide employee information for lost-time claims.
Download Supplemental Employee Forms - Lost Time Only (opens in a new tab)Medical Release for Injured Workers, NH
Authorize release of medical information for a claim.
Download Medical Release for Injured Workers, NH (opens in a new tab)NH Task Analysis Form
Document job duties and physical requirements.
Download NH Task Analysis Form (opens in a new tab)NH Second Injury Fund Employee Information Sheet
Provide employee information for Second Injury Fund review.
Download NH Second Injury Fund Employee Information Sheet (opens in a new tab)A.I.M. Vantage Occupational Health Urgent Care Centers
Find occupational health urgent care center information for workplace injury care.
Download A.I.M. Vantage Occupational Health Urgent Care Centers (opens in a new tab)Connecticut Claim Forms
Claim Kit - CT
Forms and guidance for Connecticut workplace injury claims.
Download Claim Kit - CT (opens in a new tab)Employer’s First Report of Occupational Injury or Illness
Use if reporting a Connecticut claim by fax.
Download Employer’s First Report of Occupational Injury or Illness (opens in a new tab)Filing Status and Exemption, Form 1A
Provide filing status or exemption information.
Download Filing Status and Exemption, Form 1A (opens in a new tab)Employee Medical and Work Status
Document medical status and work capacity.
Download Employee Medical and Work Status (opens in a new tab)HIPAA Release
Authorize release of health information for a claim.
Download HIPAA Release (opens in a new tab)Connecticut Managed Care Preferred Provider for Employers
Access managed care provider information for claims.
Download Connecticut Managed Care Preferred Provider for Employers (opens in a new tab)CT Primary Care Facility Poster, Spanish
Spanish-language primary care facility poster.
Download CT Primary Care Facility Poster, Spanish (opens in a new tab)CT Notice to Employees, Spanish
Spanish-language workers’ compensation notice for employees.
Download CT Notice to Employees, Spanish (opens in a new tab)CorVel PPO Lookup
Find participating providers in the CorVel network.
Visit Site CorVel PPO Lookup (opens in a new tab)Vermont Claim Forms
Claim Kit - VT
Forms and guidance for Vermont workplace injury claims.
Download Claim Kit - VT (opens in a new tab)Form 1 - Employer First Report of Injury
Use if reporting a Vermont claim by fax.
Download Form 1 - Employer First Report of Injury (opens in a new tab)Form 7 - Workers’ Compensation Medical Authorization
Authorize release of medical information for a claim.
Download Form 7 - Workers’ Compensation Medical Authorization (opens in a new tab)Form 8 - Notice of Intent to Change Healthcare Provider
Provide notice of a healthcare provider change.
Download Form 8 - Notice of Intent to Change Healthcare Provider (opens in a new tab)Form 10 - Certificate of Dependency and Concurrent Employment
Report dependency or concurrent employment information.
Download Form 10 - Certificate of Dependency and Concurrent Employment (opens in a new tab)Form 25 - Wage Statement
Report wage information for a claim.
Download Form 25 - Wage Statement (opens in a new tab)Form 4 - Report of Fatal Accident
Report a fatal workplace accident.
Download Form 4 - Report of Fatal Accident (opens in a new tab)A.I.M. Vantage Occupational Health Urgent Care Centers
Find occupational health urgent care center information for workplace injury care.
Download A.I.M. Vantage Occupational Health Urgent Care Centers (opens in a new tab)Maine Claim Forms
Claim Kit - ME
Forms and guidance for Maine workplace injury claims.
Download Claim Kit - ME (opens in a new tab)WCB-1 Employer’s First Report of Occupational Injury or Disease
Use if reporting a Maine claim by fax.
Download WCB-1 Employer’s First Report of Occupational Injury or Disease (opens in a new tab)WCB-2 Wage Statement
Report wage information for a claim.
Download WCB-2 Wage Statement (opens in a new tab)WCB-2B Fringe Benefits Worksheet
Report fringe benefit information for a claim.
Download WCB-2B Fringe Benefits Worksheet (opens in a new tab)WCB-220 Limited Release of Medical/Health Care Information
Authorize limited release of medical or healthcare information.
Download WCB-220 Limited Release of Medical/Health Care Information (opens in a new tab)Rhode Island Claim Forms
Rhode Island Claim Kit
Forms and guidance for Rhode Island workplace injury claims.
Download Rhode Island Claim Kit (opens in a new tab)DWC01 Employer’s First Report of Alleged Occupational Injury, Disease, or Fatality
Use if reporting a Rhode Island claim by fax.
Download DWC01 Employer’s First Report of Alleged Occupational Injury, Disease, or Fatality (opens in a new tab)DWC03 F Wage Statement - Full-Time
Report wage information for a full-time employee.
Download DWC03 F Wage Statement - Full-Time (opens in a new tab)DWC03 P Wage Statement - Part-Time
Report wage information for a part-time employee.
Download DWC03 P Wage Statement - Part-Time (opens in a new tab)DWC03 S Wage Statement - Seasonal
Report wage information for a seasonal employee.
Download DWC03 S Wage Statement - Seasonal (opens in a new tab)Medical Release
Authorize release of medical information for a claim.
Download Medical Release (opens in a new tab)Notice Independent Contractor Forms
Forms related to independent contractor status.
Download Notice Independent Contractor Forms (opens in a new tab)DWC 11 IC Contractor Designation
Designate an individual as an independent contractor.
Download DWC 11 IC Contractor Designation (opens in a new tab)DWC 11 Waiver
Request a waiver related to independent contractor status.
Download DWC 11 Waiver (opens in a new tab)Stay at Work & Return to Work
Stay at Work/Return to Work Guide
Guidance for stay-at-work and return-to-work planning, communication, and support after a workplace injury.
Download Stay at Work/Return to Work Guide (opens in a new tab)Modified Duty Guide for Construction
Guidance for identifying modified duty opportunities in construction settings.
Download Modified Duty Guide for Construction (opens in a new tab)Modified Duty Guide for Health Care
Guidance for identifying modified duty opportunities in health care settings.
Download Modified Duty Guide for Health Care (opens in a new tab)Modified Duty Guide for Manufacturing
Guidance for identifying modified duty opportunities in manufacturing settings.
Download Modified Duty Guide for Manufacturing (opens in a new tab)Modified Duty Guide for Service Industries
Guidance for identifying modified duty opportunities in service industry settings.
Download Modified Duty Guide for Service Industries (opens in a new tab)Modified Duty Guide for Transportation
Guidance for identifying modified duty opportunities in transportation settings.
Download Modified Duty Guide for Transportation (opens in a new tab)Posting Notices
A.I.M. Vantage Workplace Posting
A.I.M. Vantage workplace posting for workplace display.
Download A.I.M. Vantage Workplace Posting (opens in a new tab)A.I.M. Vantage Workplace Posting - Spanish
Spanish-language A.I.M. Vantage workplace posting for workplace display.
Download A.I.M. Vantage Workplace Posting - Spanish (opens in a new tab)MA Notice to Employees - Spanish
Spanish-language workers’ compensation notice.
Download MA Notice to Employees - Spanish (opens in a new tab)MA Notice to Employees - English
English-language workers’ compensation notice.
Download MA Notice to Employees - English (opens in a new tab)State of NH Worker’s Compensation Law Poster
Workers’ compensation law poster for workplace display.
Download State of NH Worker’s Compensation Law Poster (opens in a new tab)CT Notice to Employees
Connecticut workers’ compensation notice for workplace display.
Download CT Notice to Employees (opens in a new tab)ME Notice to Employees
Maine workers’ compensation notice for workplace display.
Download ME Notice to Employees (opens in a new tab)RI Notice to Employees
Rhode Island workers’ compensation notice for workplace display.
Download RI Notice to Employees (opens in a new tab)VT Notice to Employees
Vermont workers’ compensation notice for workplace display.
Download VT Notice to Employees (opens in a new tab)VT Workers’ Compensation Reinstatement Rights Notice
Vermont notice outlining workers’ compensation reinstatement rights.
Download VT Workers’ Compensation Reinstatement Rights Notice (opens in a new tab)Need Help Finding a Form?
If you’re not sure which form applies, contact A.I.M. Mutual before submitting. We’ll help you find the right document or connect you with the right team.