This form is filed by insurance carriers when weekly benefits are paid within 14 calendar days of insurer's receipt of a First Report of Injury/Death form (Form 101), or an initial written claim for weekly benefits on a Form 110 (Employee Claim Form). This form should be mailed to the Department Of Industrial Accidents at the address on the top of the form with a copy going to the Employee and to the Employer.

Print Form 103  pdf format of Form 103