Industrial Accident Compensation Application Form

1
 CLAIM FOR MEDICAL CARE EXPENSES      (209)   VIEW    
2
 Agent Appointment_Dismissal Report Form      (232)   VIEW    
3
 Claim and Certificate For Insurance Benefit Substitution Payment      (231)   VIEW    
4
 Report of Accident Caused by a Third Party      (284)   VIEW    
5
 Request for examination(Workers’ Compensation Insurance)      (422)   VIEW    
6
 Request for Reexamination(Workers’ Compensation Insurance)      (277)   VIEW    
7
 CLAIM FOR □SURVIVOR’S BENEFITS (SB) □PNEUMOCONIOSIS SURVIVOR’S ANNUITIES □FUNERAL EXPENSES (FX)      (178)   VIEW    
8
 CLAIM FOR PERMANENT DISABILITY BENEFITS (PDB) □APPLICATION FOR COMPLICATIONS, ETC PREVENTION PROGRAM      (246)   VIEW    
9
 Partial Unemployment Benefits Claim Form      (209)   VIEW    
10
 CLAIM FOR □TEMPORARY DISABILITY BENEFITS(TDB) □INJURY-DISEASE COMPENSATION ANNUITY(IDCA)      (211)   VIEW    
11
 (Commute Accident Report Form) In cases there is a perpetrator.      (263)   VIEW    
12
 (Commute Accident Report Form) n cases where there is no perpetrator.      (231)   VIEW    
13
 APPLICATION (CLAIM) FOR MEDICAL CARE BENEFITS AND CLOSING BENEFITS (INITIAL)      (373)   VIEW