Employer Forms


Insurance Coverage Status Form:  By law all businesses must submit this form to the Industrial Accident Board and Delaware's Division of Revenue to notify the State: (1) of their insurance coverage; (2) that they are legally self-insured; (3) that they are exempt from the Workmen's Compensation Law (only businesses engaged in farming or those with no employees); or (4) to allow subcontractors in the construction industry to give proper notice as required by 19 Del. C. § 2311.


Employee's Statement of Facts:  Delaware requires every employee alleging a work injury to complete all information on the Statement of Facts form for his Employer.  We recommend that all Employers have their employees prepare this form on the date of accident as a matter of company policy, sign the form and then place a copy in the employee's personnel file in the event litigation arises.  The information on this form can be critical to a successful Employer defense.  A variation of this form is used in death cases.


Employer's First Report of Injury:  Within ten days after an Employer is notified that an industrial accident allegedly injured its employee, the Employer must complete and file the Employer's First Report of Injury with the Industrial Accident Board and send a copy to its Insurer.  Employers who fail to do so are subjected to fines; yet, it is also in Employers' best interest that they make the "first" report rather than someone planning to sue them. To prevent fraud, we strongly urge our clients to sign the form.


Employer's Supplemental Report of Injury:  If Employer's First Report of Injury did not show the injured employee returned to work, an Employer's Supplemental Report of Injury must be completed and filed with the Industrial Accident Board immediately after he does return to work; or at the end of disability when compensation has been paid under an Agreement.  In the event of the employee's death, this report should be filed immediately


Employer's Modified Duty Form:  If the Employer can offer a modified duty job to the employee then an Employer's Modified Duty Form should be completed as soon as possible and forwarded to his physician with instructions to indicate whether the job is approved, sign and return the form to the Employer within fourteen days.  If the parties have entered into an Agreement, a copy of this form must accompany the Agreement when filed with the Industrial Accident Board.


Certificate of Bond:  Always maintain the requisite insurance coverage.  Should a claim be filed against an Employer who has failed to obtain insurance then, after a hearing, the Industrial Accident Board may order the Employer to post a surety bond in an amount fair to the Employer to secure funds for the employee should the claim be held compensable.  After securing the appropriate bond, the Employer and bondsman complete and file this form with the Industrial Accident Board.

Insurer Forms


Extension of Time to Decide Claim:  This form allows insurance adjustors, self-insured employers and third party administrators to request and receive an extension of time from the Industrial Accident Board in order to investigate a claim more fully before making a final determination as to whether they will accept or deny the claim.  If they do ultimately decide to accept the claim, it is imperative that they use the Agreement and Receipt forms below.


Notice of Denial Form:  Insurance adjustors, self-insured employers and third party administrators use this form to notify employees and the Industrial Accident Board that they are denying a claim and the reasons therefor.  Please note that the second to last option should only be selected when denying a claim for additional benefits on a claim for which the Employer previously accepted liability as documented on an I.A.B. Agreement signed by both parties.


Offer to Accept Claim:  If an insurance adjustor, self-insured employer or third party administrator will offer to accept liability on a claim, they can use this form to notify the employee and Industrial Accident Board of this while making their offer strictly contingent on the employee and a witness signing and returning to them the I.A.B. Agreement they prepared (below) to memorialize exactly what they will agree to accept.  This is only an offer.  No Agreement?  No deal.


Agreement as to Compensation:  If the Employer and Insurance Carrier agree to accept liability on a claim then the Employer's attorney or Insurer's adjustor must execute this Agreement as to Compensation form with the employee and file it with the Industrial Accident Board for approval.


Agreement as to Compensation for Death:  If the Employer and Insurance Carrier agree to accept liability where the employee died as a result of an industrial accident the Insurer or self-insured Employer must complete this Agreement as to Compensation for Death form with the employee's estate and file it with the Industrial Accident Board for approval.


Receipt for Compensation Paid:  Insurance Carriers and Employers must file this Receipt for Compensation to report to the Industrial Accident Board when the injured employee has received payment for any item covered under Delaware's Workmen's Compensation Law of 1917 as amended.  It is imperative to file this so that the statute of limitations will begin to count down.

I.A.B. Litigation Forms


Utilization Review Request Form:  Employers or Insurance Carriers may engage in Utilization Review to evaluate the quality, reasonableness and/or necessity of proposed or provided health care services for acknowledged compensable claims.  The Utilization Review company is randomly selected by the Department of Labor after the Employer or Insurance Carrier completes this form and mails it, along with the required documentation, to the Department of Labor pursuant to the instructions found on the second page of this document.


Pretrial Memorandum:  If the parties could not reach an Agreement on a claim (see Agreement forms above) or if they wish to appeal an adverse utilization review finding to the Industrial Accident Board, the petitioner (either the Employer, Insurer or Employee) must complete this Pretrial Memorandum and provide it to the responding party so that both parties can list the issues in dispute and defenses to be raised at hearing.  Once completed by both parties it must be filed with the Industrial Accident Board.


Petition to Appeal Utilization Review:  An Employer or Insurer who disagrees with a Utilization Review determination may file this Petition to Appeal the Utilization Review with the Industrial Accident Board as part of Delaware's Workmen's Compensation Health Care Payment System.  The appealing party must file this Petition with the Industrial Accident Board within 45 days of receiving the U.R. determination.