Catastrophic designation 2026

1. Click ‘Get Form’ to open the Employee’s Request for Catastrophic Designation in the editor.
2. Begin by filling out Section 1, which includes your identifying information. Enter your last name, first name, occupation, treating physician's name, date of injury, and other relevant details.
3. In Section 2, specify the catastrophic rehabilitation supplier you are requesting. Ensure that this supplier is authorized to provide services once the Board issues an Administrative Decision.
4. Complete Section 3 by detailing your education level and work history for the past 15 years. Include physical requirements for each job held during this period.
5. Attach a statement from your authorized treating physician regarding your work ability, ensuring it is dated within one year of submission.
6. In Section 4, certify that you have sent copies of this request to all relevant parties and complete the Certificate of Service section.
7. Finally, review all sections for accuracy before submitting your form through our platform.

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