Self Insured Semiannual report Of Claim Payments {BWC-1301}

BWC-1301 - SELF-INSURED SEMIANNUAL REPORT OF CLAIM PAYMENTS. This form is from the Bureau of Workers' Compensation and used to report claim payments made by self-insured employers for each lost-time claim active during a six-month period or after an injured worker has returned to work if sooner than six months. The form includes fields for information such as the injured worker's name, date of injury, BWC claim number, employer name, BWC policy number, allowed conditions, disability reimbursement request, disability dates (quit work and return to work), compensation paid (including type, period, number of weeks, rate, and total amount paid), medical expenses paid, certification, injured worker's signature, employer's signature, and compensation type codes. www.FormsWorkflow.com