Authorization to Release Claim Information

Authorization to Release Claim Information - (Forms/Publications)
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Title Authorization to Release Claim Information (A fillable form - 114 KB PDF)

Used by the worker to designate a person(s) as an authorized representative for the worker's claim. An authorized representative can access claim information.

Form number F101-010-000
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Keywords claims, designee, espanol, industrial insurance, spanish, worker's compensation, workers compensation, workers' compensation
Languages English , Spanish
Valid dates 03-2014
Contact information Managing Injured Workers' Claims
Claims for Job Injuries
Web pages Workers' Comp Claims

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