Request For Assistance By Injured Worker {RFA-1W}

RFA-1W - REQUEST FOR ASSISTANCE BY INJURED WORKER. You may file t form (RFA-1W) and any attachments with the Workers' Compensation Board when you want the Board to take a specific action in your claim, or if you need to alert the Board to any problem or situation that is affecting your claim. Many of the most frequently requested actions/situations are listed as either compensation payment issues (items a through g), or medical issues (items h through I), but you are not limited to those listed. Check all that apply and/or add additional information or explanation in the space provided (m or n). This form is not to be used to report an injury. To file a claim, use Form C-3. www.FormsWorkflow.com