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Claims Forms - Indiana
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First Report of Injury

NOTE: Adobe Acrobat Approval, Standard, or Professional version 5 or newer is required for submitting this form by email.

Please report injuries to mcim as soon as possible.

Wage Statement Declaración del Salario
This form is necessary in all lost time cases where wages will be paid to the injured worker. The Worker’s Compensation Act requires that we have 52 weeks of prior wage information whenever possible to determine the rate at which they will be paid.

Mileage Reimbursement Petición de Reembolso del Kilometraje
This form is included for the worker’s convenience in requesting reimbursement for mileage incurred traveling to medical appointments in connection with the injury. Injured Worker’s can submit thoroughly completed forms to their examiner.

Medical Authorization Autorización Médica
Authorization to obtain medical information.

Employee Questionnaire Cuestionario al Empleado
Initial Form to be completed by the injured worker.

Witness Statement
Form to be completed by a witness to the accident.

Fraud Investigation Notice  

Accident Investigation Report  

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