Application for Wage Loss Compensation (C-140) |
Introduction |
The injured worker and the physician of record must complete this form for the injured worker to apply for wage loss compensation. While you may complete the C-140 online, you must print it off after completion to submit either by mail or fax. |
|
Required information |
Injured worker - Claim number
- Name
- Address
- Phone number
- Date of birth
- Social Security number
- Occupation at time of injury
- Injury employer's name, address and phone number
- Dates and type of wage loss being applied for
- Work history information including: employer names, dates of employment, job titles, reasons for leaving and earnings
|
Physician - Name
- Address
- Telephone number
- Injured worker information including: date of last medical examination, restrictions (permanent and/or temporary) as a result of the allowed conditions in the claim, duration of temporary restrictions (if applicable), and any other restrictions (not related to claim)
- Injured worker physical capacity for: sitting, standing, and walking; bending, squatting, crawling, climbing, reaching; lifting; carrying; use of hands in repetitive actions such as grasping, pushing and pulling arm controls, and fine manipultation; and use of feet in repetitive movements of leg controls
|
|
Complete the form |
If you have all the required information on hand, simply click the start button to begin. |
|