Industrial Accident Compensation Application Form

1
 CLAIM FOR MEDICAL CARE EXPENSES      (225)   VIEW    
2
 Agent Appointment_Dismissal Report Form      (248)   VIEW    
3
 Claim and Certificate For Insurance Benefit Substitution Payment      (244)   VIEW    
4
 Report of Accident Caused by a Third Party      (319)   VIEW    
5
 Request for examination(Workers’ Compensation Insurance)      (489)   VIEW    
6
 Request for Reexamination(Workers’ Compensation Insurance)      (292)   VIEW    
7
 CLAIM FOR □SURVIVOR’S BENEFITS (SB) □PNEUMOCONIOSIS SURVIVOR’S ANNUITIES □FUNERAL EXPENSES (FX)      (187)   VIEW    
8
 CLAIM FOR PERMANENT DISABILITY BENEFITS (PDB) □APPLICATION FOR COMPLICATIONS, ETC PREVENTION PROGRAM      (262)   VIEW    
9
 Partial Unemployment Benefits Claim Form      (219)   VIEW    
10
 CLAIM FOR □TEMPORARY DISABILITY BENEFITS(TDB) □INJURY-DISEASE COMPENSATION ANNUITY(IDCA)      (231)   VIEW    
11
 (Commute Accident Report Form) In cases there is a perpetrator.      (290)   VIEW    
12
 (Commute Accident Report Form) n cases where there is no perpetrator.      (241)   VIEW    
13
 APPLICATION (CLAIM) FOR MEDICAL CARE BENEFITS AND CLOSING BENEFITS (INITIAL)      (424)   VIEW