Industrial Accident Compensation Application Form

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 CLAIM FOR □SURVIVOR’S BENEFITS (SB) □PNEUMOCONIOSIS SURVIVOR’S ANNUITIES □FUNERAL EXPENSES (FX)        VIEW    
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 CLAIM FOR PERMANENT DISABILITY BENEFITS (PDB) □APPLICATION FOR COMPLICATIONS, ETC PREVENTION PROGRAM        VIEW    
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 CLAIM FOR □TEMPORARY DISABILITY BENEFITS(TDB) □INJURY-DISEASE COMPENSATION ANNUITY(IDCA)        VIEW    
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 APPLICATION (CLAIM) FOR MEDICAL CARE BENEFITS AND CLOSING BENEFITS (INITIAL)        VIEW