This form is used by any party that has provided service or made payments for which it is entitled to reimbursement under the workers' compensation law.

If filing a lien (Block 13): You must state the nature of services rendered, and statutory basis for your claim.

If filing a claim (Block 14): For payment or reimbursement for services provided the employee, you must state the nature of the services rendered and the statutory basis for your claim.

NOTE: Either Box 13 or Box 14 must be completed - but not both.

Print Form 115  pdf format of form-115.pdf

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