Forms
All files are PDFs. Right click on link and select save link as or save target as to save a copy to your hard drive. Then, open the form, print it and fill out. Some forms are fillable so you have the option to email also.
A POLICYHOLDER’S GUIDE TO A POLICY TO DO MORE
- Introduction to Policyholder’s Guide
- Section I: Accident/Injuries Section of Policyholder’s Guide
- Section II: Policy Services Section of Policyholder’s Guide
- Section III: Drug-Free Workplace Section of Policyholder’s Guide
- Section IV: Safety Management Services Section of Policyholder’s Guide
- Section V: WECARE Managed Care Section of Policyholder’s Guide
- Section VI: Fraud Prevention Section of Policyholder’s Guide
- Section VII: State Specific Section of Policyholder’s Guide
ALABAMA FORMS
- Alabama Specific Section of Policyholder’s Guide
- Alabama First Report of Injury | login
- Alabama Corporate Exclusion
- Alabama Wage Statement
- Alabama Drug Free Certification
- myMatrixx Pharmacy Program Kit
- Introductory Letter to Physician/Medical Treatment Authorization
- No Injury Certificate
- Dissatisfaction of Procedure and Form
- Claim Supplementary Report
- Claim Summary Report
- Employee Managed Care Agreement
- Employee Consent to Drug and Alcohol Testing
FLORIDA FORMS
- Florida Specific Section of Policyholder’s Guide
- Florida First Report of Injury | login
- Florida Wage Statement
- WECARE Managed Care Program
- Certification for Safety Credit
- Contractor’s Premium Credit Application
- Notice of Exception to be Exempt
- Drug-Free Premium Credit Application
- Introductory Letter to Physician/Medical Treatment Authorization
- No Injury Certificate
- Grievance Procedure and Form
- Employee Managed Care Agreement
- myMatrixx Pharmacy Program Kit
- Employee Consent to Drug and Alcohol Testing
GEORGIA FORMS
- Georgia Specific Section of Policyholder’s Guide
- Georgia First Report of Injury | login
- Georgia Bill of Rights for the Injured Worker – English | Spanish
- Georgia Wage Statement
- WECARE Managed Care Program
- Drug-Free Workplace Programs
- Employee Managed Care Agreement
- Grievance Procedure and Form
- Rejection of Coverage
- No Injury Certificate
- Introductory Letter to Physician/Medical Treatment Authorization
- myMatrixx Pharmacy Program Kit
- Employee Consent to Drug and Alcohol Testing
KENTUCKY FORMS
- Kentucky Specific Section of Policyholder’s Guide
- Kentucky First Report of Injury | login
- Application for Resolution of Injury Claim
- No Injury Certificate
- Application for Resolution of Occupational Disease Claim
- Application for Resolution of Hearing Loss Claim
- Wage Certification
- Grievance Procedure and Form
- Employee Managed Care Agreement
- Introductory Letter to Physician/Medical Treatment Authorization
- Kentucky Drug-Free Workplace Program
- Employee’s Notice of Rejection of Workers’ Compensation Act
- myMatrixx Pharmacy Program Kit
- Employee Consent to Drug and Alcohol Testing
NORTH CAROLINA FORMS
- North Carolina Specific Section of Policyholder’s Guide
- North Carolina First Report of Injury | login
- North Carolina Wage Statement
- North Carolina Return To Work Form
- Employee Managed Care Agreement
- North Carolina Rejection of Coverage
- Dissatisfaction of Procedure and FormNo Injury Certificate
- Introductory Letter to Physician/Medical Treatment Authorization
- myMatrixx Pharmacy Program KitNorth Carolina Drug Free Workplace
- Employee Consent to Drug and Alcohol Testing
SOUTH CAROLINA FORMS
- South Carolina Specific Section of Policyholder’s Guide
- South Carolina First Report of Injury | login
- South Carolina Wage Statement
- South Carolina Employer’s Withdrawal of Election to Adopt the SC Workers’ Compensation Act
- South Carolina Application for Drug- and Alcohol-Free Workplace Premium Credit Program
- Employee Managed Care Agreement
- Officer Notice to Reject Coverage
- Dissatisfaction of Procedure and FormNo Injury Certificate
- Introductory Letter to Physician/Medical Treatment Authorization
- myMatrixx Pharmacy Program Kit
- Employee Consent to Drug and Alcohol Testing
VIRGINIA FORMS
- Virginia Specific Section of Policyholder’s Guide
- Virginia Employer’s Accident Report (formerly First Report of Injury) | login
- Claim Form for Benefits
- Employer’s Wage Statement of Earnings
- Attending Physicians Report
- Rejection of Coverage – Form 16A
- Notice Terminating Prior Rejection of Coverage – Form 17A
- Drug Free Certification Checklist
- No Injury Certificate
- Dissatisfaction of Procedure and Form
- Introductory Letter to Physician/Medical Treatment Authorization
- Workplace Poster
- Employee Managed Care Agreement
- myMatrixx Pharmacy Program Kit
- Virginia Drug Free Workplace
- Employee Consent to Drug and Alcohol Testing
COVENTRY MEDICAL PROVIDER
CLAIMS MANAGEMENT FORMS – ALL STATES
- Supervisor’s Accident Investigation
- No Injury Certificate
- myMatrixx Pharmacy Program Kit
- Introductory Letter to Physician/Medical Treatment Authorization
- Refusal of Treatment – English
- Refusal of Treatment – Spanish
- Provider Nomination Form
EMPLOYMENT FORMS
- Employee Managed Care Agreement
- Medical History Questionnaire
- Letter of Agreement w/Independent Contractor
- Post-Injury Drug Testing Consent
BILLING
MISCELLANEOUS
APPLICATIONS – Fax to FHM at 1-407-926-9419
- Electronic Premium Payment Authorization
- Post-Injury Drug Testing Kit
- Post-Injury Drug Testing Application
PAYROLL AUDIT FORMS
SAFETY & LOSS CONTROL
