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Click ‘Get Form’ to open the WC-14 in the editor.
Begin by selecting the appropriate option at the top of the form: 'NOTICE OF CLAIM ONLY', 'REQUEST HEARING / NOTICE OF CLAIM', or 'REQUEST FOR MEDIATION / NOTICE OF CLAIM'.
Fill in your personal details, including your last name, first name, middle initial, and Social Security Number or Board Tracking Number.
Provide the date of injury and additional claim information such as birthdate, county of injury, and your address.
Complete sections for employer and insurer details. Ensure to include names, addresses, and contact information accurately.
In section B, indicate any hearing or mediation issues by checking relevant boxes and providing dates for benefits if applicable.
Affirm the accuracy of your information in section C by signing and dating where indicated.
Finally, certify that you have sent copies of this form to all parties involved as stated in section E.
Start filling out your WC-14 form online for free today!
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