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 form.