C. L. 331 - Revised Forms 101, 110 and 116

CIRCULAR LETTER #331

TO:               All Interested Parties

FROM:          Paul V. Buckley, Commissioner

RE:               Revised Forms -

101 - Employer’s First Report of Injury or Fatality
110 – Employee’s Claim
116 – Request Lump Sum Conference

Date:            May 21, 2009

__________________________________________________________

Please be advised, effective today Form 101 – Employer’s First Report of Injury or Fatality, Form 110 – Employee’s Claim and Form 116 – Request for Lump Sum Conference have been modified. The revised forms now include fields for the Insurer’s Case/Claim number. These revised forms should be used from this point forward. All older versions of these forms filed with DIA will be accepted.

Paul V. Buckley
Commissioner