Alabama State of Alabama —http://www.al.gov/ Department of Industrial Relations —http://dir.alabama.gov/ Phyllis Kennedy , Director, (334) 242-8990, Fax: (334) 242-3960, [email protected]Donald K. Fisher , Assistant Director, (334) 242-8990, Fax: (334) 242-3960, [email protected]Workers’ Compensation Division —http://dir.alabama.gov/wc/ Industrial Relations Building 649 Monroe Street Montgomery, Alabama 36131 (800) 528-5166, (334) 242-2868; Fax: (334) 353-8262 (Administrative/TPAs/Assessments/Self-Insurance), (334) 353-8228 (Examiners/Ombudsman), (334) 353-0840 (Claims), (334) 353-8490 (Compliance/Drug Free/Medical/Education); Fraud: (800) 923-2533; Ombudsman: (800) 528-5166, (334) 242-2868 (in Montgomery area) Scottie Spates, Director, Administrative Section, (800) 528-5166, (334) 353- 0990, Fax: (334) 353-8262, [email protected]Return to top of page Alaska State of Alaska —http://www.state.ak.us/ Department of Labor and Workforce Development — http://www.labor.state.ak.us/home.htm Workers’ Compensation Division —http://www.labor.state.ak.us/wc/wc.htm Post Office Box 25512 Juneau, Alaska 99802-5512 (907) 465-2790; Fax: (907) 465-2797 Paul L. Grossi, Director, (907) 465-6046, Fax: (907) 465-2797, [email protected]Mark R. Torgerson, Chief of Adjudications, (907) 269-4982, [email protected]Workers’ Compensation Board — http://www.gov.state.ak.us/boards/factsheet/fact110.html Department of Labor
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Alabama
State of Alabama—http://www.al.gov/ Department of Industrial Relations—http://dir.alabama.gov/ Phyllis Kennedy, Director, (334) 242-8990, Fax: (334) 242-3960, [email protected] Donald K. Fisher, Assistant Director, (334) 242-8990, Fax: (334) 242-3960, [email protected] Workers’ Compensation Division—http://dir.alabama.gov/wc/ Industrial Relations Building 649 Monroe Street Montgomery, Alabama 36131 (800) 528-5166, (334) 242-2868; Fax: (334) 353-8262 (Administrative/TPAs/Assessments/Self-Insurance), (334) 353-8228 (Examiners/Ombudsman), (334) 353-0840 (Claims), (334) 353-8490 (Compliance/Drug Free/Medical/Education); Fraud: (800) 923-2533; Ombudsman: (800) 528-5166, (334) 242-2868 (in Montgomery area) Scottie Spates, Director, Administrative Section, (800) 528-5166, (334) 353-0990, Fax: (334) 353-8262, [email protected]
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Alaska
State of Alaska—http://www.state.ak.us/ Department of Labor and Workforce Development—http://www.labor.state.ak.us/home.htm Workers’ Compensation Division—http://www.labor.state.ak.us/wc/wc.htm Post Office Box 25512 Juneau, Alaska 99802-5512 (907) 465-2790; Fax: (907) 465-2797 Paul L. Grossi, Director, (907) 465-6046, Fax: (907) 465-2797, [email protected] Mark R. Torgerson, Chief of Adjudications, (907) 269-4982, [email protected]
Workers’ Compensation Board—http://www.gov.state.ak.us/boards/factsheet/fact110.html Department of Labor
Post Office Box 25512 M/S 0700 Juneau, Alaska 99802-5512 (907) 465-2790, Fax: (907) 465-2797 Commissioner of Labor Ed Flanagan, Chairman [email protected] John A. Abshire, At Large/Labor Valerie K. Baffone, 3rd Judicial District/Labor Dorothy Bradshaw, 2nd/4th Judicial District/Industry John Giuchici, 2nd/4th Judicial District/Labor Paul Grossi, Commissioner of Labor or his designee Steve Hagedorn, 3rd Judicial District/Industry Harriet M. Lawlor, 3rd Judicial District/Labor Andrew J. Piekarski, 3rd Judicial District/Labor Nancy Jo Ridgley, 1st Judicial District/Labor Florence S. Rooney, 3rd Judicial District/Industry Marc D. Stemp, At Large/Industry Philip E. Ulmer, 3rd Judicial District/Industry James G. Williams, 1st Judicial District/Industry
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Arizona
State of Arizona—http://www.state.az.us/ Industrial Commission of Arizona—http://www.ica.state.az.us/ 800 West Washington Phoenix, Arizona 85007 or Post Office Box 19070 Phoenix, Arizona 85005-9070 (602) 542-4411, Fax: (602) 542-7889; Ombudsman: (602) 542-4538, Fax: (602) 542-4350 Gay Conrad Kruglick, Chairman Mike Petchel, Vice Chairman Jean-Pierre Angelchick, M.D., Commissioner Sandy Grunow, Commissioner Lou Rodriguez, Commissioner Larry J. Etchechury, Director Teresa Hilton, Secretary Click here to download free fillable PDF (Portable Document Format) versions
of Arizona workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
Industrial Commission Review Board
State Compensation Fund (SCF Arizona)—http://www.scfaz.com/ 3031 North Second Street Phoenix, Arizona 85012 (602) 631-2000; Fax: (602) 631-2213 Donald A. Smith, Jr., President and CEO
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Arkansas
State of Arkansas—http://www.state.ar.us/ Workers’ Compensation Commission—http://www.awcc.state.ar.us/ Street Address: 324 Spring Street Little Rock, Arkansas 72203 Mailing Address: Post Office Box 950 Little Rock, Arkansas 72203-0950 (800) 622-4472, (501) 682-3930; Fax: (501) 682-2777; Legal Advisor Direct: (800) 250-2511; TDD: (800) 285-1131 Arkansas Relay System TDD: (800) 285-1131 Olan W. “Butch” Reeves, Chairman, [email protected] Karen H. McKinney, Commissioner, [email protected] Shelby W. “Terry” Turner, Commissioner,[email protected] Alan McClain, Chief Executive Officer, [email protected] James W. Daniel, Assistant Chief Executive Officer, [email protected] David Greenbaum, Chief Administrative Law Judge, [email protected]
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California
State of California—http://www.ca.gov/ Department of Industrial Relations—http://www.dir.ca.gov/ Christine Baker, Acting Director
Commission on Health and Safety and Workers’ Compensation (CHSWC)—http://www.dir.ca.gov/chswc/chswc.html 1515 Clay Street, Room 901 Oakland, California 94612 (510) 622-3959, Fax: (510) 622-3265 E-mail: [email protected] Chairman Angie Wei, Labor Representative Commission Members: http://www.dir.ca.gov/chswc/Members.htm Catherine “Cathy” Aguilar, Employer Representative Allen Davenport, Labor Representative Sean McNally, Employer Representative Kristen Schwenkmeyer, Employer Representative Robert B. Steinberg, Employer Representative Darrel“Shorty” Thacker, Labor Representative Christine Baker, Executive Officer, (510) 622-3959, Fax: (510) 622-3265
Division of Workers’ Compensation (DWC)—http://www.dir.ca.gov/dwc/dwc_home_page.htm Street Address: 1515 Clay Street, 17th Floor Oakland, California 94612 Mailing Address: Post Office Box 420603 San Francisco, California 94142 (800) 736-7401, (510) 286-7100 E-mail: [email protected] Rosa Moran, Administrative Director Keven Star, Court Administrator Click here to download free fillable PDF (Portable Document Format) versions of California workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
Division of Workers’ Compensation Medical Unit—http://www.dir.ca.gov/dwc/MedicalUnit/imchp.html Street Address: 1515 Clay Street, 18th Floor Oakland, California 94612 Mailing Address: Post Office Box 71010 San Francisco, California 94142
(800) 794-6900 (in California), (510) 286-3700, Complaint Line: (800) 999-1041 Anne Searcy, MD, Executive Medical Director
Workers’ Compensation Appeals Board (WCAB)—http://www.dir.ca.gov/WCAB/ Street Address: 455 Golden Gate Avenue, Suite 9328 San Francisco, California 94102-3660 Mailing Address: Post Office Box 429459 San Francisco, California 94142-9459 Information and Assistance Division: (800) 736-7401, (415) 703-5020 Commissioners Joseph M. Miller, Chairman, (415) 703-4554 Frank M. Brass, Commissioner Ronnie Caplane, Commissioner James C. Cuneo, Commissioner Alfonso J. Moresi, Commissioner Janice Murray, Commissioner William K. O’Brien, Commissioner Deputy Commissioners Dennis J. Hannigan, Secretary Rick Dietrich, Assistant Secretary Neil P. Sullivan, Assistant Secretary
Self-Insurance Plans (SIP)—http://www.dir.ca.gov/SIP/ 2265 Watt Avenue, Suite 1 Sacramento, California 95825 (916) 574-0300, Fax: (916) 483-1535 E-mail: [email protected] Mark Johnson, Chief James Ware, Manager Jamie Meyers, Marilee Robinson, and Ken Swanson, Supervisors
State Compensation Insurance Fund (SCIF)—http://www.scif.com/ 1275 Market Street San Francisco, California 94103 (415) 565-1234, Claims Reporting Service (toll free): (888) 222-3211, Fraud Hotline: (888) 786-7372 Janet Frank, President James F. Neary and John E. Putnam, Executive Vice Presidents
Connie Raiche, Don L. Smith, Harrison D. Jerome, Linda T. Hoban, Nancy A. Obertello, and David West, Vice Presidents Directors Jeanne Cain, Chair of the Board and Senior Vice President of the California Chamber of Commerce Sheryl Chalupa, President and Chief Executive Officer of Goodwill Industries of South Central California and Vice Chair of California Council of Goodwill Industries Vincent Mudd, President and Chief Executive Officer of San Diego Office Interiors Francis Quinlan, Partner in Kester & Quinlan, LLP James A. Santangelo, President of Joint Council 42 of the Teamsters Union and Secretary-Treasurer of Local 848 Ex-officio Board Members John C. Duncan, Director of the Department of Industrial Relations Jay Hansen, designee of the Assembly and Legislative Director of the State Building & Construction Trades Council Don Moulds, designee of the Senate and Vice President of Medical & Regulatory Policy, California Medical Association
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Colorado
State of Colorado—http://www.colorado.gov/ Department of Labor & Employment—http://www.coworkforce.com/ 633 17th Street, Suite 200 Denver, Colorado 80202-3660 Donald J. Mares, Executive Director, (303) 318-8020 Division of Workers’ Compensation—http://www.coworkforce.com/dwc/ 633 17th Street, Suite 400 Denver, Colorado 80202-3660 (888) 390-7936 (English), (800) 685-0891 (Spanish), (303) 318-8700, Fax:(303) 318-8710, E-mail: [email protected] Bob Summers, Director, (303) 318-8014 Paul Tauriello, Deputy Director, (303) 318-8650 Click here to download free fillable PDF (Portable Document Format) versions of Colorado workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
Industrial Claims Appeals Office(ICAP)—http://www.coworkforce.com/icao/ 633 17th Street, Suite 600 Denver, Colorado 80202-3660 (303) 318-8131, Fax: (303) 318-8139 Dona Halsey, Director
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Connecticut
State of Connecticut—http://www.ct.gov/ Workers’ Compensation Commission—http://wcc.state.ct.us/ Capitol Place 21 Oak Street, Fourth Floor Hartford, Connecticut 06106 (800) 223-9675 (toll-free in Connecticut), (860) 493-1500, Fax: (860) 247-1361 [email protected] John A. Mastropietro, Chairman Amado J. Vargas, Commissioner Stephen B. Delaney, Commissioner Ernie R. Walker, Commissioner Charles F. Senich, Commissioner Michelle D. Truglia, Commissioner Nancy E. Salerno, Commissioner Scott A. Barton, Commissioner Peter Mlynarczyk, Commissioner Jack R. Goldberg, Commissioner Randy L. Cohen, Commissioner Jodi Murray Gregg, Commissioner Christine L. Engel, Commissioner Daniel E. Dilzer, Commissioner David W. Schoolcraft, Commissioner Clifton E. Thompson, Commissioner Marvin L. Smernoff, Chief Administrative Officer Click here to download free fillable PDF (Portable Document Format) versions of Connecticut workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
Compensation Review Board (CRB)—http://wcc.state.ct.us/wcc/crb.htm Capitol Place
21 Oak Street, Fourth Floor Hartford, Connecticut 06106 (203) 493-1500, Fax: (203) 247-1361 John A. Mastropietro, Chairman
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Delaware
State of Delaware—http://delaware.gov/ Department of Labor—http://www.delawareworks.com/ 4425 North Market Street Wilmington, Delaware 19802 [email protected] Thomas B. Sharp, Secretary, (302) 761-8000, Fax: (302) 761-6621 Division of Industrial Affairs—http://www.delawareworks.com/industrialaffairs/ 4425 North Market Street, Third Floor Wilmington, Delaware 19802 (302) 761-8200 (New Castle), (302) 422-1134 (Kent and Sussex) John Kirk III, Director, (302) 761-8176, Fax: (302) 761-6601, [email protected] Office of Workers’ Compensation—http://www.delawareworks.com/industrialaffairs/services/WorkersComp.shtml Street Address: Fox Valley Office 4425 North Market Street Wilmington, Delaware 19802 Mailing Address: Post Office Box 9954 Wilmington, Delaware 19802-9954 (302) 761-8200 (New Castle), (302) 422-1134 (Kent and Sussex), Fax: (302) 761-6601 John F. Kirk, III, Deputy Director Lowell L. Groundland, Chair Harold B. Barber, Member Elaine Bowen, Member John D. Daniello, Member Mary L. Dantzler, Member Marilyn Doto, Member
Victor Epolito, Member Alice Mitchell, Member Romayne Seward, Member Terrence Shannon, Member
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District of Columbia
District of Columbia—http://www.dc.gov/ Department of Employment Services—http://www.does.dc.gov/does/site/default.asp Government of the District of Columbia 64 New York Avenue, N.E. Washington, District of Columbia 20002 (202) 724-7000, Fax: (202) 724-5683, TDD/TYY: (202) 673-6994 E-mail: [email protected]
Labor Standards Bureau 64 New York Avenue, N.E., Room 3129 Washington, District of Columbia 20002 (202) 671-1555, Fax: (202) 673-6412 Reginald H. Berry, Assistant Director
Office of Workers’ Compensation—http://www.does.dc.gov/does/cwp/view.asp?a=1232&Q=537428 Mailing Address: Post Office Box 56098 Washington, District of Columbia 20002 Street Address: 64 New York Avenue, N.E., Room 2909 Washington, District of Columbia 20002 (202) 671-1000, Fax: (202) 671-1929 Charles L. Green, Associate Director
Office of Hearings and Adjudication—http://www.does.dc.gov/does/cwp/view.asp?a=1232&Q=537904 64 New York Avenue, N.E., Room 2011 Washington, District of Columbia 20002 (202) 671-2233, Fax: (202) 673-6938 Malcolm J. Luis-Harper, Chief Administrative Law Judge
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Florida
State of Florida—http://www.myflorida.com/ Florida Department of Financial Services—http://www.myfloridacfo.com/ Alex Sink, Chief Financial Officer, [email protected] 200 East Gaines Street Tallahassee, FL 32399-0300 (850) 413-3100, Consumer Helpline: (800) 342-2762 Division of Workers’ Compensation—http://www.myfloridacfo.com/WC/ 200 East Gaines Street Tallahassee, Florida 32399-4220 (850) 413-1609; Fax: (850) 922-6779; Injured Worker Helpline: (800) 742-2214; Fraud: (800) 742-2214 (in Florida) (Department of Insurance, Bureau of Workers’ Compensation Fraud: (850) 413-3116); Safety: (800) 367-4378 (in Florida), (850) 488-3044 E-mail: [email protected] Tanner Holloman, Director, (850) 488-2514,[email protected] Andrew Sabolic, Assistant Director, [email protected] Click here to download free fillable PDF (Portable Document Format) versions of Florida workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
Florida Division of Administrative Hearings—http://www.doah.state.fl.us/internet/ The Desoto Building 1230 Apalachee Parkway Tallahassee, Florida 32301-3060 (850) 488-9675; Fax: (850) 921-6847 Robert S. Cohen, Director and Chief Judge Claudia Llado, Clerk of the Division, [email protected] Office of Judges of Compensation Claims—http://www.jcc.state.fl.us/jcc/ Petition for Benefits: Post Office Box 8000 Tallahassee, Florida 32314-8000 Filing: Post Office Box 8000 Tallahassee, Florida 32314-8000 Request for Assignment of Case Number:
Post Office Box 8000 Tallahassee, Florida 32314-8000 (850) 487-1911, SUNCOM 277-1911 David W. Langham, Deputy Chief Judge
Florida Department of Education—http://www.fldoe.org/ Florida Division of Vocational Rehabilitation—http://www.rehabworks.org/ 2002 Old Saint Augustine Road, Building A Tallahassee, Florida 32301-4862 (800) 451-4327 (Voice/TDD), (850) 245-3399 (Voice/TDD) Bill Palmer, Director
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Georgia
State of Georgia—http://www.georgia.gov/ Georgia State Board of Workers’ Compensation—http://sbwc.georgia.gov/portal/site/SBWC/ 270 Peachtree Street, NW Atlanta, Georgia 30303-1299 (800) 533-0682, (404) 656-3875, Fax: (404) 656-7768, Enforcement Division: (404) 657-1391, Safety Library: (404) 656-9057 Richard S. Thompson, Chairman, (404) 656-2034 Stephen B. Farrow, Director, (404) 656-2038 Warren Massey, Director, (404) 656-2036 Stan Carter, Executive Director and Chief Operating Officer, (404) 656-2048 Thomas M. Risko, Chief Financial Officer, (404) 656-2314 Marianne McMillan, Director, Licensure and Self-Insurance, (404) 656-4893 Click here to download free fillable PDF (Portable Document Format) versions of Georgia workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
Georgia Subsequent Injury Trust Fund—http://sitf.georgia.gov/portal/site/SITF/ Marquis Two Tower, Suite 1250 285 Peachtree Center Avenue NE Atlanta, Georgia 30303 (404) 656-7000, Fax: (404) 206-656-7100 Mike Coan, Administrator, (404) 656-7013, [email protected] Allan Payne, Deputy Administrator, (404) 656-7062, [email protected]
Kathy Cannon, Director of Administrative Services, (404) 656-7022, [email protected]
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Hawaii
State of Hawaii—http://www.hawaii.gov/portal/ Department of Labor & Industrial Relations(DLIR)—http://hawaii.gov/labor/ Nelson B. Befitel, Director, (808) 586-8844, Fax:(808) 586-9099, [email protected] 830 Punchbowl Street Honolulu, Hawaii 96813 (808) 586-8842, Fax: (808) 586-9099, [email protected]
Disability Compensation Division—http://hawaii.gov/labor/dcd/index.shtml 830 Punchbowl Street, #211 Honolulu, Hawaii 96813 (808) 586-9151, Fax: (808) 586-9219, [email protected] Gary Hamada, Administrator
State of Idaho—http://www.idaho.gov/ Idaho Industrial Commission—http://www.iic.idaho.gov/ Street Address: 317 Main Street Boise, Idaho 83720 Mailing Address: Post Office Box 83720 Boise, Idaho 83720-0041 (800) 950-2110, (208) 334-6000; Fax: (208) 334-2321; TDD: (800) 950-2110
Thomas Limbaugh, Chairman (employer representative), (208) 334-6000 James F. Kile, Commissioner (attorney representative), (208) 334-6000 R. D. Maynard, Commissioner (employee representative), (208) 334-6000 Mindy Montgomery, Director, (208) 334-6059 Nancy Beeson, Secretary, (208) 334-6017, [email protected]
State Insurance Fund—http://www.idahosif.org/ 1215 West State Street Post Office Box 83720 Boise, Idaho 83720-0044 (800) 334-2370, (208) 334-2370 (in the Boise area); Fax: (208) 334-2262 (Policyholder Services, Administration, Management Services, Legal), (208) 334-3253 (Claims), (208) 334-3254 (Underwriting); Fraud: (800) 448-ISIF (4743) E-mail addresses: Claims: [email protected] Customer Service Center: [email protected] Fraud: [email protected] General Information/News Media Inquiries: [email protected] Management Services: [email protected] Manager’s Office: [email protected] Policyholder Services: [email protected] Underwriting: [email protected]
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Illinois
State of Illinois—http://www.il.gov/ Illinois Workers’ Compensation Commission—http://www.iwcc.il.gov/ 100 West Randolph Street, Suite 8-200 Chicago, Illinois 60601 (866) 352-3033(toll free within Illinois), (312) 814-6611, Fax: (312) 814-6523, TDD: (312) 814-2959 E-mail: [email protected] Commissioners Mitch Weisz, Chairman, (312) 814-6560, [email protected] Mario Basurto, Commissioner, (312) 814-5641, [email protected] Yolaine Dauphin, Commissioner, (312) 814-1110, [email protected] James F. DeMunno, Commissioner, (312) 814-6606, [email protected]
Dan Donohoo, Commissioner, (312) 814-6058, [email protected] David Gore, Commissioner, (312) 814-1211, [email protected] Kevin Lamborn, Commissioner, (312) 814-1522, [email protected] Nancy Lindsay, Commissioner, (312) 814-1157, [email protected] Molly Mason, Commissioner, (312) 814-6601, [email protected] Thomas Tyrrell, Commissioner, (312) 814-6603, [email protected] Administrator Kimberly Janas, Secretary of the Commission/Chief of Staff, (312) 814-6559, [email protected] Commission Review Board: http://www.iwcc.il.gov/boards.htm#CRB Self-Insurers Advisory Board: http://www.iwcc.il.gov/boards.htm#ISIAB Workers’ Compensation Advisory Board: http://www.iwcc.il.gov/boards.htm#WCAB Workers’ Compensation Medical Fee Advisory Board: http://www.iwcc.il.gov/boards.htm#WCMFAB Click here to download free fillable PDF (Portable Document Format) versions of Illinois workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
Illinois Workers’ Compensation Commission Office of Self-Insurance Administration—http://www.iwcc.il.gov/selfinsurance.htm E-mail: [email protected] Maria Sarli-Dehlin, Manager of Self-Insurance,(312) 814-6065, [email protected] Springfield Office 701 South Second Street Springfield, Illinois 62704 (217) 785-7084, Fax: (217) 785-6557 Chicago Office 100 West Randolph Street, Eighth floor Chicago, Illinois 60601 (312) 814-6065
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Indiana
State of Indiana—http://www.in.gov/ Workers’ Compensation Board of Indiana—http://www.in.gov/workcomp/ Government Center South
402 West Washington Street, Room W-196 Indianapolis, Indiana 46204 (317) 232-3808; Claims/Statistics: (317) 233-4930; Fax: (317) 233-5493; Insurance: (317) 233-3910; Ombudsman: (800) 824-COMP (2667), (317) 232-5922 G. Terrence Coriden, Chairman, (317) 232-3808 Rogelio Dominquez, Member, (317) 232-5922 Douglas Meagher, Member, (317) 233-5397 Richard J. Noel, Member, (317) 233-3906 Linda Powell, Member, (317) 233-3908 John Rader, Member, (317) 233-3904 Anne Thomas, Member, (317) 232-5922 Sandy Cerimele Fralich, Executive Secretary, (317) 232-3809
Indiana Compensation Rating Bureau (ICRB)—http://www.icrb.net/ Street Address: 5920 Castleway West Drive Indianapolis, Indiana 46250 Mailing Address: Post Office Box 50400 Indianapolis, Indiana 46250 (800) 622-4208, (317) 842-2800; Fax: (317) 842-3717 E-mail: [email protected] Ronald W. Cooper, CWCP, President, [email protected]
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Iowa
State of Iowa—http://www.iowa.gov/ Iowa Workforce Development—http://www.iowaworkforce.org/ 1000 East Grand Avenue Des Moines, Iowa 50319-0209 (800) JOB-IOWA, (515) 281-5387 Elisabeth Buck, Director Iowa Division of Workers’ Compensation—http://www.iowaworkforce.org/wc/ 1000 East Grand Avenue Des Moines, Iowa 50319-0209 (800) JOB-IOWA (562-4692), (515) 281-5387; Fax: (515) 281-6501, TTD: (515) 281-4748
State of Kansas—http://www.kansas.gov/ Department of Labor—http://www.dol.ks.gov/ 401 SW Topeka Boulevard Topeka, Kansas 66603-3182 (785) 296-5000 Jim Garner, Secretary Division of Workers’ Compensation—http://www.dol.ks.gov/WC/HTML/wc_ALL.html 800 SW Jackson, Suite 600 Topeka, Kansas 66612-1227 (800) 332-0353, (785) 296-2996; Fax: (785) 296-0839; Fraud: (800) 332-0353, (785) 296-6392; Industrial Safety & Health: (800) 332-0353, (785) 296-4386; Ombudsman: (800) 332-0353, (785) 296-2996 Paula Greathouse, Director, (785) 296-2996
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Kentucky
Commonwealth of Kentucky—http://kentucky.gov/ Kentucky Department of Labor—http://www.labor.ky.gov/ 1047 U.S. 127 South, Suite 4 Frankfort, Kentucky 40601 (502) 564-3070, Fax: (502) 564-5387 J.R. Gray, Secretary, (502) 564-0685, Fax: (502) 684-5387 Department of Workers’ Claims—http://www.labor.ky.gov/workersclaims/ 657 Chamberlin Avenue Frankfort, Kentucky 40601 (502) 564-5550 (Administrative Services, Open Records); Fax: (502) 564-
8250(Administrative Services), (502) 564-9533 (Specialists), (502) 564-5732 (Open Records), (502) 564-0916 (Security and Compliance) Specialists Toll Free Number: (800) 554-8601 E-mail: Department of Workers’ Claims Dwight T. Lovan, Commissioner, (502) 782-4439; Fax: (502) 564-5934 Wayne Logan, Deputy Commissioner, (502) 782-4482; Fax: (502) 564-5934 John Burkholder, Director of Security and Compliance,(502) 782-4534; Fax: (502) 564-0916 Ingrid Bowling, Director of Claims Processing and Appeals,(502) 782-4418; Fax: (502) 564-3792 Fran Davis, Director of Information and Research,(502) 782-4578; Fax: (502) 564-5732 Lucretia Johnson, Director of Specialists Services Division,(502) 782-4559; Fax: (502) 564-9533 Scott Borders, Acting Chief Administrative Law Judge, (502) 782-4446, Fax: (502) 564-0682 John W. Mann, Chief Workers' Compensation Specialist, (502) 782-4532; Fax: (502) 564-9533 Charlie Lowther, General Counsel, (502) 782-4464; Fax: (502) 564-5934 Click here to download free fillable PDF (Portable Document Format) versions of Kentucky workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
Workers’ Compensation Board—http://www.labor.ky.gov/workersclaims/workerscompboard.htm Michael W. Alvey, Chairman, (270) 926-9494 Franklin A. Stivers, Member, (606) 330-2171 Bruce Cowden, Member, (859) 246-2773 Division of Workers’ Compensation Funds—http://www.labor.ky.gov/ows/workerscompensationfunds/ 1047 U.S. 127 South, Suite 4 Frankfort, Kentucky 40601 (502) 564-5467; Fax: (502) 564-5112 Robert L. Whittaker, Director,(502) 564-3083; Fax: (502) 564-5112
Workers’ Compensation Funding Commission—http://www.kwcfc.ky.gov/ Street Address: #42 Millcreek Park Frankfort, Kentucky 40601 Mailing Address:
Post Office Box 1228 Frankfort, Kentucky 40602-1228 (502) 573-3505, Fax: (502) 573-4023 Gordon Stammel, (502) 573-3505, ext. 228; [email protected]
Kentucky Workers’ Compensation Law (via CompEd, Inc.)—http://www.comped.net/
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Louisiana
State of Louisiana—http://www.louisiana.gov/wps/portal/ Department of Labor—http://www.laworks.net/ Mailing Address: Post Office Box 94094 Baton Rouge, Louisiana 70804-9094 Street Address: 1001 North 23rd Street Baton Rouge, Louisiana 70804-9094 (225) 342-3111, TDD: (800) 259-5154 John Warner Smith, Secretary of Labor Office of Workers’ Compensation Administration—http://www.laworks.net/wrk_owca.asp Mailing Address: Post Office Box 94040 Baton Rouge, Louisiana 70804-9040 Street Address: 1001 North 23rd Street Baton Rouge, Louisiana 70802-9094 (225) 342-7555, Fax: (225) 342-5665, Fraud: (800) 201-3362 or [email protected], Safety:(800) 201-2497 E-mail: [email protected] Karen Reiners Winfrey, Assistant Secretary of Labor
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Maine
State of Maine—http://www.maine.gov/ Workers’ Compensation Board—http://www.maine.gov/wcb/ 27 State House Station Augusta, Maine 04333-0027 (207) 287-3751; Fax: (207) 287-7198 Board of Directors Paul R. Dionne, Chair, (207) 287-7086 Management Representatives James A. Mingo, Board Member, (207) 287-7096 Mitchell P. Sammons, Board Member, (207) 287-7096 Sophia Wilson, Board Member, (207) 287-7096 Labor Representatives Daniel Lawson, Board Member, (207) 287-7096 Anthony Monfiletto, Board Member, (207) 287-7096 Ginette Rivard, Board Member, (207) 287-7096 Staff Members Paul R. Dionne, Executive Director, (207) 287-7086 Richard Dunn, Deputy Director, Business Services, (207) 287-7083 Steven P. Minkowsky, Deputy Director, Monitoring, Audit, and Enforcement Program,(207) 287-7067, [email protected] Elizabeth Inman, Deputy Director, Office of Medical Rehabilitation Services,(207) 941-4557, [email protected] John Rohde, General Counsel, (207) 287-7086 Click here to download free fillable PDF (Portable Document Format) versions of Maine workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
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Maryland
State of Maryland—http://www.maryland.gov/ Workers’ Compensation Commission—http://www.wcc.state.md.us/ 10 East Baltimore Street Baltimore, Maryland 21202-1641 (800) 492-0479, (410) 864-5100; Fax: (410) 333-8122; Fraud: (800) 846-4069;[email protected] R. Karl Aumann, Chairman, (410) 864-5300 Patricia G. Adams, Commissioner, (410) 864-5365 Jeffrey C. Herwig, Commissioner, (410) 864-5179 Kenneth G. Macleay, Commissioner, (410) 864-5135
Cynthia S. Miraglia, Commissioner, (410) 864-5130 Maureen Quinn, Commissioner, (410) 864-5270 Lauren Sfekas, Commissioner, (410) 864-5238 Kimberly Smith Ward, Commissioner, (410) 864-5112 John R. Webster, Jr., Commissioner, (410) 864-5340 Jeffrey T. Weinberg, Commissioner, (410) 864- 5276 Mary K. Ahearn, Executive Director of Administration,(410) 864-5308 Click here to download free fillable PDF (Portable Document Format) versions of Maryland workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
Insured Workers’ Insurance Fund—http://www.iwif.com/ 8722 Loch Raven Boulevard Towson, Maryland 21286-2235 (800) 264-IWIF (4943), (410) 494-2000; Fax: (410) 494-2001; Injury Reporting Hotline: (888) 410-1400; Fraud:(888) ANTI-FRAUD (268-4372), [email protected] Thomas J. Phelan, CPA, President and Chief Executive Officer Paige Beck, CPA, Executive Vice President and Chief Financial Officer Dennis W. Carroll, Esq., Executive Vice President and General Counsel Robert E. Merritt, CFA, Executive Vice President and Chief Investment Officer George H. Matthews, AAI, Executive Vice President, Insurance Operations Timothy K. Michels, Esq., Executive Vice President, Claims Rona S. Finkelstein, Esq., Senior Vice President, Legal Services & Human Resources Donna C. Wilson, Senior Vice President, Strategic Planning and Communications Rial R. Simons, FCAS, MAAA, Chief Actuary Elbert Danquah, Vice President, Internal Audit Kama Kolbe, Vice President, Underwriting Frank Linardi, Jr., CPA, Vice President, Finance and Controller Robert Marshall, Vice President, Information Systems Nancy Wilson, Vice President, Claims Board of Directors Rocky V. Gonzalez, Chairman R. Bruce Alderman, Esq., Vice Chairman Patricia McHugh Lambert, Secretary Frank D. Boston, Jr., Treasurer Joseph M. Coale, Board Member Charles Dankmeyer, Board Member
Queen Logan Gladden, Board Member Kenneth Nwafor, Board Member Leonard “Bud” Schuler, Jr., Board Member
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Massachusetts
Commonwealth of Massachusetts—http://www.mass.gov/ Department of Industrial Accidents—http://www.mass.gov/dia/ 600 Washington Street, Seventh Floor Boston, Massachusetts 02111 (800) 323-3249, (617) 727-4900; Fax: (617) 727-6477; TTY: (800) 224-6196 Paul V. Buckley, Commissioner Tim McMahon, Deputy Commissioner William C. Tattan, Deputy Commissioner Martine Carroll, Senior Judge Click here to download free fillable PDF (Portable Document Format) versions of Massachusetts workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
Massachusetts Workers’ Compensation Advisory Council—http://www.mass.gov/wcac/ 600 Washington Street, Seventh Floor Boston, Massachusetts 02111 (617) 727-4900, ext. 378; Fax: (617) 727-7122 Edmund C. Corcoran, Jr., Chairman Mickey Long, Vice Chairman Andrew S. Burton, Executive Director
Workers’Compensation Rating and Inspection Bureau of Massachusetts—https://www.wcribma.org/mass/ 101 Arch Street Boston, Massachusetts 02110 (617) 439-9030, Fax: (617) 439-6055 Paul F. Meagher, President
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Michigan
State of Michigan—http://www.michigan.gov/ Department ofLabor & Economic Growth—http://www.michigan.gov/cis Street Address: 611 W. Ottawa Lansing, Michigan 48909 Mailing Address: Post Office Box 30004 Lansing, Michigan 48909 (517) 373-1820, Fax: (517) 373-2129 David C. Hollister, Director Workers’ Compensation Agency—http://www.michigan.gov/wca Street Address: State Secondary Complex General Office Building 7150 Harris Drive 1st Floor, B-Wing Lansing, Michigan 48913 Mailing Address: Post Office Box 30016 Lansing, Michigan 48909 (888) 396-5041,(313) 456-2400, Fax: (313) 456-2424 E-mail: [email protected] Kevin A. Elsenheimer, Director, (517) 322-1106, Fax: (517) 322-6689, [email protected] Jack A. Nolish, Deputy Director, (517) 322-1106, Fax: (517) 322-6689, [email protected] Sue Bickel, Secretary, (517) 322-1106, Fax: (517) 322-6689, [email protected] Click here to download free fillable PDF (Portable Document Format) versions of Michigan workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
Workers’ Compensation Appellate Commission—http://www.michigan.gov/cis/0,1607,7-154-10576_17495---,00.html Street Address: Ottawa Building, 2nd Floor 611 West Ottawa Street Lansing, Michigan 48909 Mailing Address: Post Office Box 30468 Lansing, Michigan 48909-7968 (517) 373-8020, Fax: (517) 241-1396 E-mail:[email protected] Martha M. Glaser, Chairperson James J. Kent Gregory A. Przybylo Granner S. Ries Rodger G. Will
Michigan Economic Development Corporation—http://medc.michigan.org/ 300 North Washington Square Lansing, Michigan 48913 (888) 522-0103, (517) 373-9808 James C. Epolito, President and Chief Executive Officer Sanford “Sandy” Ring, Chief Operating Officer Michigan Business Guide to Workers’ Compensation—http://medc.michigan.org/services/workerscomp/ Compensation Cost Control Service Victor Office Center, Fourth Floor 201 North Washington Square Lansing, Michigan 48909-7968 (517) 373-9809, Fax: (517) 241-3689
Compensation Advisory Organization of Michigan (CAOM)—http://www.caom.com/ Street Address: 17197 North Laurel Park Drive, Suite 311 Livonia, Michigan 48152 Mailing Address: Post Office Box 3337 Livonia, Michigan 48151-3337 (734) 462-9600, Fax: (734) 462-9721 Jerry J. Stage, President and Chief Executive Officer
Jon D. Heikkinen, Senior Vice President, CAOM Operations Gary L. Thompson, Vice President, Facility Operations
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Minnesota
State of Minnesota—http://www.mn.gov/ Department of Labor and Industry—http://www.dli.mn.gov/ 443 Lafayette Road North St. Paul, Minnesota 55155-4307 (800) DIAL-DLI (342-5354), (651) 284-5005; TTY: (651) 297-4198 Steve Sviggum, Commissioner
Workers’ Compensation Division—http://www.dli.mn.gov/WorkComp.asp 443 Lafayette Road North St. Paul, Minnesota 55155 (800) DIAL-DLI (342-5354)in Greater Minnesota, (651) 284-5005 in the St. Paul area, (800) 365-4584 or (218) 733-7810 in the Duluth area; Fax: (651) 284-5727 E-mail: [email protected] Beth Hargarten, Assistant Commissioner Click here to download free fillable PDF (Portable Document Format) versions of Minnesota workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
Workers’ Compensation Court of Appeals—http://www.workerscomp.state.mn.us/ 405 Minnesota Judicial Center 25 Dr. Martin Luther King Jr. Boulevard St. Paul, Minnesota 55155 (651) 296-6526, Fax: (651) 297-2520, TTY/TDD: (800) 627-3529 Thomas L. Johnson, Chief Judge William R. Pederson, Judge Miriam P. Rykken, Judge David A. Stofferahn, Judge Debra A. Wilson, Judge
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Mississippi
State of Mississippi—http://www.ms.gov/ Mississippi Workers’ Compensation Commission—http://www.mwcc.state.ms.us/ Street Address: 1428 Lakeland Drive Jackson, Mississippi 39216 Mailing Address: Post Office Box 5300 Jackson, Mississippi 39296-5300 (866) 473-6922, (601) 987-4200, Fraud: (601) 359-4250 Liles Williams, Chairman, (601) 987-4258, [email protected] Debra Gibbs, Commissioner, (601) 987-4254, [email protected] John Junkin, Commissioner, (601) 987-4254, [email protected] Ray C. Minor, Executive Director, (601) 987-4205, [email protected] Phyllis Clark, Commission Secretary, (601) 987-4252, [email protected]
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Missouri
State of Missouri—http://www.mo.gov/ Department of Labor and Industrial Relations—http://www.labor.mo.gov/ Street Address: 3315 West Truman Boulevard, Room 213 Jefferson City, Missouri 65102 Mailing Address: Post Office Box 504 Jefferson City, Missouri 65102-0504 (573) 751-9691, Fax: (573) 751-4135 Lawrence G. Rebman, Director, (573) 751-9691, Fax: (573) 751-4135, E-mail: [email protected]
• Division of Workers’ Compensation—http://www.labor.mo.gov/DWC/
State of Montana—http://mt.gov/ Department of Labor and Industry—http://dli.mt.gov/ Post Office Box 1728 Helena, Montana 59624-1728 (406) 444-2840, Fax: (406) 444-1394 E-mail: [email protected] Keith Kelley, Commissioner
Employment Relations Division—http://erd.dli.mt.gov/ Street Address: 1805 Prospect Avenue
Helena, MT 59624 Mailing Address: Post Office 8011 Helena, MT 59604-8011 (406) 444-6543 Jerry Keck, Administrator
Montana State Fund—http://www.montanastatefund.com/ Street Address: 855 Front Street Helena, Montana 59601 Mailing Address: Post Office Box 4759 Helena, Montana 59604-4759 Claim Reporting/Customer Service: (800) 332-6102 or (406) 444-6500, Fraud Reporting: (888) 682-7463, TDD-TTY: (406) 495-5030 Laurence Hubbard, President/CEO
Montana Self-Insurers Guaranty Fund 5865 Rosendale Road East Helena, MT 59635-9727 (406) 475-3766, [email protected] Jeff Lapham, Executive Director
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Nebraska
State of Nebraska—http://www.nebraska.gov/ Workers’ Compensation Court—http://www.wcc.ne.gov/ Street Address: Lincoln, Nebraska 68509 State House, 13th Floor Mailing Address: Post Office Box 98908 Lincoln, Nebraska 68509-8908 (800) 599-5155 (in Nebraska only), (402) 471-6468 (Lincoln and out of state), Fax: (402) 471-2700 Michael K. High, Presiding Judge Ronald L. Brown, Judge Michael P. Cavel, Judge James K. Coe, Judge J. Michael Fitzgerald, Judge John R. Hoffert, Judge Laurel K. Van Norman, Judge
State of Nevada—http://www.nv.gov/ Department of Business & Industry—http://dbi.state.nv.us/ In Northern Nevada: 788 Fairview Avenue, Suite 100 Carson City, Nevada 89701-5491 (775) 687-4250, Fax: (775) 687-4266 E-Mail: [email protected] In Southern Nevada: 555 E. Washington Avenue, Suite 4900 Las Vegas, Nevada 89101 (702) 486-2750, Fax: (702) 486-2758 E-Mail: [email protected]
Division of Industrial Relations—http://dirweb.state.nv.us/ 400 West King Street, Suite 400 Carson City, Nevada 89703 (775) 684-7260, Fax: (775) 687-6305 D. Roger Bremner, Administrator, (775) 684-7260, Fax: (775) 687-6305, [email protected] John Laxalt, Assistant Administrator, (775) 684-7263, Fax: (775) 687-6305, [email protected]
Industrial Insurance Regulation Section—http://dirweb.state.nv.us/iirs.htm 400 West King Street, Suite 400 Carson City, Nevada 89703 (775) 684-7270, Fax: (775) 687-6305
Workers’ Compensation Section—http://dirweb.state.nv.us/WCS/wcs.htm 1301 North Green Valley Parkway, Suite 200 Henderson, Nevada 89074
(702) 486-9080, Fax: (702) 990-0364 E-mail: [email protected] Charles J. Verre, Chief Administrative Officer, (702) 486-9087, [email protected] Northern District: 400 West King Street, Suite 400 Carson City, Nevada 89703 (775) 684-7270, Fax: (775) 687-6305 Charlotte LaCombe, (775) 684-7278, [email protected] Southern District: 1301 North Green Valley Parkway, Suite 200 Henderson, Nevada 89074 (702) 486-9080, Fax: (702) 990-0364 Ken Webb, Manager, (702) 486-9105, [email protected]
Nevada Attorney for Injured Workers—http://naiw.nv.gov/ Nancyann Leeder, Nevada Attorney for Injured Workers
2200 South Rancho Drive, Suite 230 Las Vegas, Nevada 89102 (702) 486-2830, Fax: (702) 486-2844 E-mail: [email protected] Gary Watson, Supervising Attorney 1000 East William Street, Suite 208 Carson City, Nevada 89701 (775) 684-7555, Fax: (775) 684-7575 E-mail: [email protected] Donna Sweger, Supervising Attorney
Douglas D. Dirks, President and Chief Executive Officer of Employers Holdings, Inc.
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New Hampshire
State of New Hampshire—http://www.nh.gov/ Department of Labor—http://www.labor.state.nh.us/ 95 Pleasant Street Concord, New Hampshire 03301 (603) 271-3177 George N. Copadis, Commissioner David M. Wihby, Deputy Commissioner Workers’ Compensation Division—http://www.labor.state.nh.us/workers_compensation.asp 95 Pleasant Street Concord, New Hampshire 03301 (603) 271-3174 (claims), (603) 271-2042 (coverage), (603) 271-6172 (self-insurance), (603) 271-3328 (vocational rehabilitation) Kathryn J. Barger, Director, (800) 272-4353, (603) 271-3176 Click here to download free fillable PDF (Portable Document Format) versions of New Hampshire workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
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New Jersey
State of New Jersey—http://www.nj.gov/ Department of Labor—http://lwd.dol.state.nj.us/labor/ John Fitch Plaza Post Office Box 110 Trenton, New Jersey 08625 (609) 292-2323, Fax: (609) 633-9271 Harold J. "Hal" Wirths, Commissioner, (609) 292-2975 Division of Workers’ Compensation—http://lwd.dol.state.nj.us/labor/wc/wc_index.html Post Office Box 381 Trenton, New Jersey 08625-0381
(609) 292-2515, Fax: (609) 984-2515 E-mail: [email protected] Peter Calderone, Chief Judge & Director, (609) 292-2414, fax: (609) 984-2515,[email protected] Renee Ricciardelli, Administrative Supervising Judge, (609) 292-2414, fax: (609) 984-2515, [email protected] Click here to download free fillable PDF (Portable Document Format) versions of New Jersey workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
N.J. Compensation Rating and Inspection Bureau—http://www.njcrib.com/ 60 Park Place Newark, New Jersey 07102 (973) 622-6014, Fax: (973) 622-6110 Grover E. Czech, Executive Director, (973) 622-6014, ext. 213 Frederick A. Huber, Associate Executive Director, (973) 622-6014, ext. 223 Roland E. Brazda III, Director, Underwriting, (973) 622-6014, ext. 214 Robert J. Eichler, Director, MIS, (973) 622-6014, ext. 275 Stanley R. Markow, Acting Director, Actuarial, (973) 622-6014, ext. 211 Salvatore A. Nardone, Director, Experience Rating, (973) 622-6014, ext. 216 Janet Nicolai, Director, Human Resources, (973) 622-6014, ext. 221 John T. Skidmore, Director, Policy Review, (973) 622-6014, ext. 217 Paul G. Witko, Director and Special Assistant to the Executive Director, (973) 622-6014, ext. 215
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New Mexico
State of New Mexico—http://www.newmexico.gov/ Workers’ Compensation Administration—http://www.workerscomp.state.nm.us/ Mailing Address: Post Office Box 27198 Albuquerque, New Mexico 87125-7198 Street Address: 2410 Centre Avenue SE Albuquerque, New Mexico 87125 (800) 255-7965, (505) 841-6000, Fax: (505) 841-6009 Help Line/Hot Line: (866) WORKOMP (967-5667), TTY/TDD: (505) 841-6043, E-mail: [email protected]
Glenn R. Smith, Director, (505) 841-6007 Abelino Montoya, Jr., Assistant Director Al Otero, Special Assistant to the Director Chris Johnston, Facilities Management Ida Alvarado, Financial Services Van Cravens, Public Information Officer, (505) 841-6004,[email protected] Greg Griego, Dispute Resolution Sharon Gentry, Office of the General Counsel Christopher Marlowe, Enforcement Laura Feight, Deputy Director, Internal Operations Division Elaine Trujillo, Deputy Director, External Operations Division Workers’ Compensation Judges Gregory D. Griego, Judge, (505) 841-6023 Terry Kramer, Judge, (505) 841-6029 Victor S. Lopez, Judge, (505) 841-6014 Juanita Roibal-Bradley, Judge Pro Tem, (505) 841-6029 Helen L. Stirling, Judge, (505) 841-6841 Advisory Council on Workers’ Compensation and Occupational Disease Disablement Nick Kapnison, Chairman, Business Member, (505) 872-1700 Mike Anaya, Business Member, (505) 832-4715 or832-4391 Emily Kane, Labor Member, (505) 841-6000 Mark G. Henderson, Business Member, (505) 292-8955 Jude McMullen, Labor Member, (505) 841-6000 Fidel A. Munoz, Labor Member, (505) 265-7933 Glenn R. Smith, Ex-Officio Member, (505) 841-6007
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New York
State of New York—http://www.ny.gov/ New York State Workers’ Compensation Board—http://www.wcb.state.ny.us/ 20 Park Street Albany, New York 12207 (877) 632-4996, Fax: (518) 473-1415, Fraud: (888) 363-6001 E-mail: [email protected] Robert E. Beloten, Chair Frances M. Libous, RN, BS, Vice Chair
Mona A. Bargnesi, Member Richard A. Bell, Member Donna Ferrara, Member Candace K. Finnegan, Member Freida Foster, Member Mark D. Higgins, Member Conrad W. Lower, Member Ellen O. Paprocki, Member Glenn Warren, Executive Director Advocate for Business, (800) 628-3331 Edwin Ruff, Advocate for Injured Workers, (800) 580-6665, (518) 474-8182, Fax: (518) 486-7510 Click here to download free fillable PDF (Portable Document Format) versions of New York workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
New York State Insurance Fund—http://www.nysif.com/ 199 Church Street New York, New York 10007 (888) 875-5790, (212) 312-9000, Fax: (212) 385-2073 Robert H. Hurlbut, Chairman H. Sidney Holmes III, Vice Chairman David P. Wehner, Executive Director/Chief Executive Officer
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North Carolina
State of North Carolina—http://www.ncgov.com/ Department of Commerce—http://www.nccommerce.com/ Mailing Address: 4301 Mail Service Center Raleigh, North Carolina 27699-4301 Street Address: 301 North Wilmington Street Raleigh, NC 27020-0571 (919) 733-4151 E-mail: [email protected] J. Keith Crisco, Secretary
North Carolina Industrial Commission—http://www.ic.nc.gov/ Mailing Address: 4340 Mail Service Center Raleigh, North Carolina 27699-4340 Street Address: Dobbs Building (sixth floor) 430 North Salisbury Street Raleigh, North Carolina 27603-5937 (800) 688-8349, (919) 807-2501, Fax: (919) 715-0280, [email protected], Fraud: [email protected], Safety: [email protected] Pamela T. Young, Chair,(919) 807-2517, [email protected] Bernadine S. Ballance, Commissioner, (919) 807-2511, [email protected] Linda Cheatham, Commissioner, (919) 807-2523, [email protected] Danny Lee McDonald, Commissioner,(919) 807-2516, [email protected] Staci T. Meyer, Commissioner, (919) 807-2525, [email protected] Tammy R. Nance, Commissioner, (919) 807-2525, [email protected] Christopher Scott, Commissioner,(919) 807-2513, [email protected] Barbara Levine, Administrator,(919) 807-2525, [email protected]
Fraud Investigations Section: (888) 891-4895 (in North Carolina), [email protected]—http://www.ic.nc.gov/fraud.html Safety Education Section: (919) 807-2603, [email protected]—http://www.ic.nc.gov/safety.html Workers’ Compensation Information Specialists Section (formerly Ombudsman Section): (800) 688-8349, [email protected]—http://www.ic.nc.gov/infospec.html Click here to download free fillable PDF (Portable Document Format) versions of North Carolina workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
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North Dakota
State of North Dakota—http://www.nd.gov/ Workforce Safety & Insurance—http://www.WorkforceSafety.com/ 1600 East Century Avenue, Suite One Bismarck, North Dakota 58506-5585
(800) 777-5033, (701) 328-3800; Fax: (701) 328-3820; Fraud:(800) 243-3331; Safety and Loss Prevention: (701) 328-3886; TDD: (701) 328-3786 E-mail: [email protected] Brent J. Edison, Executive Director/CEO Workforce Safety & Insurance Board of Directors Post Office Box 2174 Bismarck, North Dakota 58502-2174 David H. Ystebo, Chairman Robert M. Indvik, Vice Chairman Richard Bergstad Mark Gjovig Sindy Keller Cal Kolling Evan Mandigo Robert Nelson Denny Schneider Nancy A. Slotten Allen “Gene” Wyman, M.D.
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Ohio
State of Ohio—http://ohio.gov/ Ohio Bureau of Workers’ Compensation—http://www.ohiobwc.com/ 30 West Spring Street Columbus, Ohio 43215-2256 E-mail: [email protected] (800) OHIOBWC (800-644-6292); Fax: (877) 520-OHIO (6446); TTY: (800) BWC-4-TDD (800-292-4833); Authorized Consent for Release of Information: Fax: (614) 621-3376; Ombudsman: (800) 335-0996, Fax: (614) 644-1998, [email protected] Marsha P. Ryan, Administrator Click here to download free fillable PDF (Portable Document Format) versions of Ohio workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
Industrial Commission of Ohio—http://www.ohioic.com/index.jsp 30 West Spring Street Columbus, Ohio 43215-2256 (800) 521-2691, (614) 466-6136, Fax: (614) 752-8304
William E. Thompson, Chairman Patrick J. Gannon, Member Barbara Knapic, Member
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Oklahoma
State of Oklahoma—http://www.ok.gov/ Oklahoma Workers’ Compensation Court—http://www.owcc.state.ok.us/ Oklahoma City Location: Denver N. Davison Court Building 1915 North Stiles Avenue Oklahoma City, Oklahoma 73105 Tulsa Location: 440 South Houston, Suite 210 Tulsa, Oklahoma 74127 (800) 522-8210 (statewide), (405) 522-8600 (Oklahoma City) and (918) 581-2714 (Tulsa), Fax: (405) 522-8687 (administration) Mary A. Black, Presiding Judge Tom Leonard, Vice Presiding Judge Richard L. Blanchard, Judge Ellen C. Edwards, Judge Kenton W. Fulton, Judge Gene Prigmore, Judge Cherri Farrar, Judge Michael J. Harkey, Judge John M. McCormick, Judge Kent Eldridge, Judge Marcia Davis, Administrator, (405) 522-8776 Mike Sykes, Supervisor, Counselors Department, (405) 522-8760 or (800) 522-8210 (statewide)
Department of Labor—http://www.okdol.state.ok.us/ 4001 North Lincoln Boulevard Oklahoma City, Oklahoma 73105-5212 (888) 269-5353, (405) 528-1500 Fax: (405) 528-5751 Lloyd L. Fields, Commissioner, (405) 528-1500, ext. 200; Fax: (405) 528-5751; [email protected] Workers’ Compensation Enforcement Unit—http://www.okdol.state.ok.us/workcomp/index.htm
Sharon Eischen, Director, [email protected] Worker Safety Policy Council—http://www.okdol.state.ok.us/wspc/index.htm Lloyd L. Fields, Chairman Clayton Abernathy, Member Scott Barger, Member Jim Bowien, Member Harry Coates, Member Steve Compton, Member Cheryl Dorrance, Member Debbe Leftwich, Member Cheryl Marcham, Member Chuck Mills, Member Gerri Mooney, Member Norma Noble, Member Robert Noll, Member Don Powers, Member Dave Koeneke, Member Mike Seney, Member Mike Wilt, Member Trebor Worthen, Member
CompSource Oklahoma—http://www.compsourceok.com/ Mailing Address (Oklahoma City): Post Office Box 53505 Oklahoma City, Oklahoma 73152-3505 Street Address (Oklahoma City): 1901 North Walnut Avenue Oklahoma City, Oklahoma 73105-3295 (800) 347-3863, (405) 232-7663; Teleclaim (to report an injury): (800) 872-7015; Claims Information: (800) 462-7966, (405) 962-3872; Fax: (405) 962-3000, Fraud Hotline:(800) 899-1847 Claims Information: [email protected], Fraud: [email protected] Street Addresses (Tulsa Branch Office): 1305 South Denver Avenue Tulsa, Oklahoma 74119-3040 Mailing Address (Tulsa Branch Office): Post Office Box 50580 Tulsa, Oklahoma 74150-0580 (800) 347-3863,(918) 295-1500 Terry McCullar, President and Chief Executive Officer, (405) 962-3334, Fax:
(405) 962-3127 Janet McFeeters, Assistant to the President, (405) 962-3262, Fax: (405) 962-3127,[email protected] Davina Craig-Sealock, Executive Secretary, (405) 962-3294, Fax: (405) 962-3127, [email protected] Lisa Blodgett, General Counsel,(405) 962-3811, Fax: (405) 962-3048, [email protected] Board of Managers: Tom Jaworsky, Chair Tony Hutchison, Vice Chair Ron Brown, Secretary Lt. Gov. Jari Askins,Member David Atkinson, Member Andy Bass, Member Betty Cairns, Member Clay Curtis, Member Pat Malloy, Member
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Oregon
State of Oregon—http://www.oregon.gov/ Department of Consumer & Business Services—http://egov.oregon.gov/DCBS/ 350 Winter Street NE Salem, Oregon 97301-3878 (503) 378-4100, Fax: (503) 378-6444 Cory Streisinger, Director, (503) 378-4100,[email protected] Greg Malkasian, Deputy Director, (503) 378-4100, Fax: (503) 378-6444,[email protected]
Workers’ Compensation Division—http://wcd.oregon.gov/ 350 Winter Street NE, Room 27 Salem, Oregon 97301-3879 (800) 452-0288 (Workers’ Compensation Infoline); (503) 947-7810, Fax: (503) 947-7514; TTY: (503) 947-7993; Fraud Hotline: (800) 422-8778 (in Oregon); Small Business Ombudsman: (503) 378-4209, Fax: (503) 373-7639; Ombudsman for Injured Workers: (800) 927-1271, (503) 378-3351, Fax: (503) 373-7639 John L. Shilts, Administrator, (503) 947-7500, Fax: (503) 947-7514,
Workers’ Compensation Board—http://www.cbs.state.or.us/external/wcb/index.html 2601 25th Street SE, Suite 150 Salem, Oregon 97302-1282 (503) 378-3308 Maureen Bock, Chairman Frank J. Biehl, Member Mustafa Kasubhai, Member Greig Lowell, Member Vera Langer, Member
Workers’ Compensation Management-Labor Advisory Committee—http://www.oregon.gov/DCBS/MLAC/ Department of Consumer & Business Services 350 Winter Street, Room 200 Salem, Oregon 97301-3878 (503) 947-7867; Fax: (503) 378-6444 Labor Representatives: Bob Shiprack, Co-Chair, Oregon Building Trades Council Lon Holston, AFSCME John Kirkpatrick, IUPAT District Council #5 Mike O’Rourke, Plumbing & Steamfitters UA 290 Brad Witt, Oregon AFL-CIO Management Representatives: J. L. Wilson, Co-Chair, NFIB/Oregon Ken Hector, CNF Service Company Diane Janzen, NorPac Sheri Sundstrom, Hoffman Construction Company of Oregon Lisa Trussell, Associated Oregon Industries Lou Savage, Administrator, (503) 378-4100,[email protected]
Ombudsman for Injured Workers—http://egov.oregon.gov/DCBS/OIW/index.shtml 350 Winter Street NE, Room 160 Salem, Oregon 97310 (800) 927-1271, (503) 378-3351 Maria A. Carraher, Ombudsman for Injured Workers [email protected]
Ombudsman for Small Business—http://egov.oregon.gov/DCBS/SBO/index.shtml 350 Winter Street NE Salem, Oregon 97301-3878 (503) 378-4209, V/TTY: (503) 378-4100 John R. Booton, Small Business Ombudsman [email protected]
SAIF Corporation—http://www.saif.com/ 400 High Street SE Salem, Oregon 97312-1000 (800) 285-8525, (503) 373-8000 Cecil W. Tibbetts, Acting President and Chief Executive Officer Jon A. Egge, Chair, Board of Directors
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Pennsylvania
State of Pennsylvania—http://www.pa.gov/portal/server.pt Department of Labor and Industry—http://www.dli.state.pa.us/ Labor & Industry Building Room 1700 7th and Forster Streets Harrisburg, Pennsylvania 17120 (717) 787-5279 Sandi Vito, Acting Secretary Bureau of Workers’ Compensation—http://www.dli.state.pa.us/landi/cwp/view.asp?a=138&q=220671 1171 South Cameron Street, Room 324 Harrisburg, Pennsylvania 17104-2501 (800) 482-2383 (inside Pennsylvania), (717) 772-4447 (local/out of state), TTY: (800) 362-4228 (for hearing and speech impaired only) E-mail: [email protected] John T. “Jack” Kupchinsky, Director,[email protected] Click here to download free fillable PDF (Portable Document Format) versions of Pennsylvania workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
State Workers’ Insurance Fund—http://www.dli.state.pa.us/landi/cwp/view.asp?a=151&q=209835 Street Address
Workers’ Compensation Appeal Board--http://www.dli.state.pa.us/landi/cwp/view.asp?a=296&q=202912 1171 South Cameron Street, Room 305 Harrisburg, Pennsylvania 17104-2511 (717) 783-7838, Fax: (717) 772-0343 Susan M. McDermott, Chairman Robert E. Giles, Secretary William R. Davis, Commissioner Harold V. Fergus, Jr., Commissioner Daniel R. Fleck, Commissioner Alfonso Frioni, Jr., Commissioner Herbert W. Hoffman, Commissioner Robert A. Krebs, Commissioner Robert T. McIntyre, Commissioner Gail L. O’Neal, Commissioner Joseph T. Rafferty, Commissioner Joseph P. Santone, Commissioner John J. Schmitt, Commissioner Harry Schwartz, Commissioner Delores Wilson, Commissioner
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Rhode Island
State of Rhode Island—http://www.state.ri.us/ Workers’ Compensation Court—http://www.courts.state.ri.us/workers/defaultnew-workers.htm One Dorrance Plaza Providence, Rhode Island 02903 (401) 458-5000, Fax: (401) 222-3121 George E. Healy, Jr.,[email protected]
Medical Advisory Board—http://www.courts.ri.gov/workers/medical/medical-advisory.htm One Dorrance Plaza Providence, Rhode Island 02903 (401) 458-3460 Vincent J. Yakavonis, MD, Chair Maureen Aveno, Administrator, [email protected] Workers’ Compensation Advisory Council 194 Smith Street Providence, Rhode Island 02908 (401) 751-7100 George Nee, Chairperson
Department of Labor and Training—http://www.dlt.ri.gov/ 1511 Pontiac Avenue Cranston, Rhode Island 02920-4407 (401) 462-8000 Adelita S. Orefice, Director, [email protected] Workers’ Compensation Division—http://www.dlt.ri.gov/wc/ Street Address: 1511 Pontiac Avenue, Building 69, Second Floor Cranston, Rhode Island 02920-0942 Mailing Address: Post Office Box 20190 Cranston, Rhode Island 02920-0190 (401) 462-8100, Fax: (401) 462-8105, TDD: (401) 462-8006 E. Jean Severance, Associate Director, (401) 462-8081, [email protected] Matthew P. Carey, III, Assistant Director, (401) 462-8127,
[email protected] Click here to download free fillable PDF (Portable Document Format) versions of Rhode Island workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
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South Carolina
State of South Carolina—http://www.sc.gov/ Workers’ Compensation Commission—http://www.wcc.sc.gov/ Street Address: 1612 Marion Street Columbia, South Carolina 29201 Mailing Address: Post Office Box 1715 Columbia, South Carolina 29202-1715 (803) 737-5700, Fax: (803) 737-5768 Andrea C. Roche, Chairman, (803) 737-5700, Fax: (803) 737-5764 Susan S. Barden, Commissioner, (803) 737-5700, Fax: (803) 737-5764 T. Scott Beck, Commissioner, (803) 737-5700, Fax: (803) 737-5764 David W. Huffstetler, Commissioner, (803) 737-5700, Fax: (803) 737-5764 G. Bryan Lyndon, Commissioner, (803) 737-5700, Fax: (803) 737-5764 Avery B. Wilkerson, Jr., Commissioner, (803) 737-5700, Fax: (803) 737-5764 Derrick L. Williams, Commissioner, (803) 737-5700, Fax: (803) 737-5764 Gary R. Thibault, Executive Director, (803) 737-5744, Fax: (803) 737-5764, [email protected] Click here to download free fillable PDF (Portable Document Format) versions of South Carolina workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
South Carolina State Accident Fund—http://www.saf.sc.gov/ Street Address: 800 Dutch Square Boulevard Columbia, South Carolina 29221 Mailing Address: Post Office Box 102100 Columbia, South Carolina 29221-5000 (800) 521-6576, (803) 896-5800 Irvin D. “Pete” Parker, Director, [email protected]
South Carolina Second Injury Fund—http://www.scsif.sc.gov/ 220 Executive Center Drive Winthrop Building, Suite 119 Columbia, South Carolina 29210 (803) 798-2722, Fax: (803) 798-5290 William E. Gunn, Director Michael T. Harris, Deputy Director Debbie Manning, Administrative Manager Pete Calamas, Director of Claims Ann P. Corley, Director of Recoveries Latonya D. Edwards, General Counsel South Carolina Workers’ Compensation Uninsured Employers’ Fund 220 Executive Center Drive Winthrop Building, Suite 119 Columbia, South Carolina 29210 (803) 798-2722, Fax: (803) 798-5290
South Carolina Self-Insurers Association—http://www.scselfinsurers.com/ 215 Holly Ridge Lane West Columbia, SC 29169 (803) 794-2080, Fax: (803) 939-8366 Mobashir “Moby” Salahuddin, Executive Director, [email protected] Board of Directors Hugh McAngus, President David Hill Keller, Vice President David Benenhaley, Secretary Brian J. Teusink, CPA, CCM, AIAF, Treasurer Sam Painter, Legal Counsel Janeen Cantillion, Board Member Jim Connor, Board Member Ted Contos, Board Member Earl Ellis, Board Member Joseph H. Hutchinson, Board Member Harvey Mathias, Board Member John Mellette, Board Member Jeffrey Ranew, Board Member Douglas Schueler, Board Member M. Clifton Scott, Board Member Kevin Thibault, Board Member Tony Timmerman, Board Member
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South Dakota
State of South Dakota—http://www.sd.gov/ Department of Labor—http://dol.sd.gov/ Pamela S. Roberts, Secretary of Labor Workers’ Compensation Program—http://dol.sd.gov/workerscomp/default.aspx Kneip Building 700 Governors Drive Pierre, South Dakota 57501-2291 E-mail: [email protected] (605) 773-3681, Fax: (605) 773-4211 James Marsh, Director Workers’ Compensation Advisory Council—http://dol.sd.gov/workerscomp/advisorycouncil.aspx Dennis Daugaard, Chair
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Tennessee
State of Tennessee—http://www.tennessee.gov/ Department of Labor and Workforce Development—http://www.tennessee.gov/labor-wfd/ Workers’ Compensation Division—http://www.state.tn.us/labor-wfd/wcomp.html 710 James Robertson Parkway Gateway Plaza, Second Floor Nashville, Tennessee 37243-0665 (800) 332-2667 (within Tennessee), (615) 532-4812, Fax: (615) 532-1468 Sue Ann Head, Administrator Blaine Sprouse, Assistant Administrator Click here to download free fillable PDF (Portable Document Format) versions of Tennessee workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
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Texas
State of Texas—http://www.state.tx.us/ Department of Insurance—http://www.tdi.state.tx.us/ Street Address 333 Guadalupe Austin, Texas 78701 Mailing Address Post Office Box 149104 Austin, Texas 78714-9104 (800) 578-4677, (512) 463-6169 Mike Geeslin, Commissioner, (512) 463-6464, Fax: (512) 475-2005 Division of Workers’ Compensation—http://www.tdi.state.tx.us/wc/indexwc.html 7551 Metro Center Drive, Suite 100 Austin, Texas 78744-1609 Main number: (512) 804-4000; Commissioner’s office: (512) 804-4435, fax: (512) 804-4401; Field Offices: (800) 252-7031 (local customer service); Fraud Hotline: (888) 327-8818 or (512) 804-4703; Safety Violations Hotline: (800) 452-9595; Technical Help Desk (TXCOMP, EDI) (888) 4-TXCOMP E-Mail: [email protected] Rod Bordelon, Commissioner of Workers’ Compensation Click here to download free fillable PDF (Portable Document Format) versions of Texas workers’ compensation forms:http://www.tdi.state.tx.us/forms/form20all.html.
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Utah
State of Utah—http://www.utah.gov/ Labor Commission—http://www.laborcommission.utah.gov/ Sherrie M. Hayashi, Commissioner Division of Industrial Accidents—http://www.laborcommission.utah.gov/IndustrialAccidents/index.html Mailing Address: Post Office Box 146610 Salt Lake City, Utah 84114-6610 Street Address: 160 East 300 South, 3rd Floor
Salt Lake City, Utah 84111 (800) 530-5090 (in state only), (801) 530-6800, Fax: (801) 530-6804, TDD: (801) 530-7685 [email protected] R. Lee Ellertson, Chairman Thomas R. Carlson, Commissioner Colleen S. Colton, Commissioner Larry D. Bunkall, Director, (801) 530-6988, Fax: (801) 530-6804, [email protected]
Workers’ Compensation Fund—https://www.wcfgroup.com/wcfWebsite/homePage.do Salt Lake City Office 392 East 6400 South Murray, Utah 84107 (800) 446-2667 Ray Pickup, President and Chief Executive Officer,(801) 288-8000 Board of Directors Robert D. Myrick, Chair Judd A. Turner , Vice Chair Dallas H. Bradford Roger Livingston Ruth Lybbert Robert B. Murray Lane A. Summerhays
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Vermont
State of Vermont—http://vermont.gov/ Department of Labor—http://labor.vermont.gov/ Street Address 5 Green Mountain Drive Montpelier, Vermont 05601-0488 Mailing Address Post Office Box 488 Montpelier, Vermont 05601-0488 (802) 828-4000, Fax: (802) 828-4022 Patricia A. McDonald, Commissioner, (802) 828-4000, [email protected]
Workers’ Compensation & Safety Division—http://labor.vermont.gov/Business/WorkersCompensation/tabid/114/Default.aspx Street Address 5 Green Mountain Drive Montpelier, Vermont 05601-0488 Mailing Address Post Office Box 488 Montpelier, Vermont 05601-0488 (802) 828-2286, Fax: (802) 828-2195 J. Stephen Monahan, Director, (802) 828-2138, [email protected] Rebecca Smith, Staff Attorney, (802) 828-2992, [email protected] Kristina Bielenberg, Supervisor, (802) 828-2286,[email protected] Click here to download free fillable PDF (Portable Document Format) versions of Vermont workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
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Virginia
Commonwealth of Virginia—http://www.virginia.gov/ Virginia Workers’ Compensation Commission—http://www.vwc.state.va.us 1000 DMV Drive Richmond, Virginia 23220 (877) 664-2566, Fax: (804) 367-9740, TDD: (804) 367-8600 E-mail: [email protected] Lawrence D. Tarr, Chairman, (804) 367-8666 Virginia R. Diamond, Commissioner, (804) 367-8657 William L. Dudley, Jr., Commissioner, (804) 367-8659 James J. Szablewicz, Chief Deputy Commissioner, (804) 367-8664 Kim Harris, Manager, Human Resources Department, (804) 367-8637 Edward P. Rice, Comptroller, (804) 367-0580 R. Temple Mayo, Director of Claims/Deputy Commissioner, (804) 367-8625 Eileen Mundok, Chief Information Officer, (877) 664-2566 Click here to download free fillable PDF (Portable Document Format) versions of Virginia workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
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Washington
State of Washington—http://access.wa.gov/ Department of Labor and Industries—http://www.lni.wa.gov/ Labor and Industries Building Post Office Box 44001 Olympia, Washington 98504-4001 (800) 547-8367, (360) 902-4200, Fax: (360) 902-4202 Judy Schurke, Director Workers’ Comp Claims—http://www.lni.wa.gov/ClaimsIns/Claims/default.asp
Board of Industrial Insurance Appeals—http://www.biia.wa.gov/ Street Address: 2430 Chandler Court, SW Olympia, Washington 98504-2401 Mailing Address: Post Office Box 42401 Olympia, Washington 98504-2401 (800) 442-0447, (360) 753-9646, Fax: (360) 586-5611 Thomas E. Egan, Chairman and Public Member Frank E. Fennerty, Jr., Labor Member Calhoun Dickinson, Employer Member Click here to download free fillable PDF (Portable Document Format) versions of Washington workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
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West Virginia
West Virginia—http://www.wv.gov/ Insurance Commission—http://www.wvinsurance.gov/ Jane L. Cline, Commissioner
BrickStreet Mutual Insurance Company—http://www.brickstreet.com/ (formerly West Virginia Workers’ Compensation Commission) Mailing Address:
Post Office Box 3824 Charleston, West Virginia 25338-3824 Street Address: 400 Quarrier Street Charleston, West Virginia 25301 Administrative Services: (888) 4-WV-COMP and(304) 926-3400, Fax: (304) 926-5372; Claims: [email protected]; Fraud:[email protected]; Insurance: (866) 45BRICK (452-7425) and (304) 941-1000, Fax: (304) 304-941-1151; Providers: [email protected]; Safety Services: [email protected] Gregory A. Burton, President and Chief Executive Officer, (304) 926-5060, [email protected] Phillip A. Lynch, Senior Vice President R. Philip Shimer, Senior Vice President, Strategic Business Group T.J. Obrokta, Jr., Senior Vice President and General Counsel J. Christopher Howat, CPA, Senior Vice President, Treasurer and Chief Financial Officer Harry Mahler, Senior Vice President, Insurance Operations Board of Directors Gregory A. Burton Thomas V. Flaherty Phillip A. Lynch David Rader Stephen Roberts H. Skip Tarasuk, Jr. Steven F. White
Workers’Compensation Office of Judges—http://www.wvinsurance.gov/ooj/ Mailing Address: Post Office Box 2233 Charleston West Virginia 25328-2233 Street Address: One Players Club Drive Charleston West Virginia 25311-1638 (304) 558-1686, Fax: (304) 558-1021 Timothy G. Leach, Chief Administrative Law Judge
Workers’Compensation Board of Review—http://www.wvinsurance.gov/boardofreview/index.htm Mailing Address:
Post Office Box 2628 Charleston, West Virginia 25329-2628 Street Address: 104 Dee Drive Charleston, West Virginia 25301 (304) 558-5230, Fax: (304) 558-1322 Robert G. Wolpert, Chair Rita Hedrick-Helmick, Member W. Jack Stevens, Member
Workers’ Compensation Industrial Council—http://www.wvinsurance.gov/wc/industrialcouncil/index.htm Charles Bayless, Chairman Bill Dean, Vice Chairman Jane L. Cline, Insurance Commissioner Robert S. Kiss, Member Dan Marshall, Member Sarah Minear, Member Brooks McCabe, Member Walter Pellish, Member Rick Slater, Member
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Wisconsin
State of Wisconsin—http://www.wisconsin.gov/state/home Department of Workforce Development—http://www.dwd.state.wi.us/ Workers’ Compensation Division—http://www.dwd.state.wi.us/wc/default.htm Mailing Address: Post Office Box 7901 Madison, Wisconsin 53707-7901 Street Address: Room C100 201 East Washington Avenue Madison, Wisconsin 53703 (608) 266-1340; Fax: (608) 267-0394; Fraud (608) 261-8486 Frances Huntley-Cooper, Administrator, (608) 266-6841, [email protected] John Conway, Deputy Administrator, (608) 266-0337,
[email protected] Jean Culbert, Administrative Support, (608) 266-6898, [email protected] Click here to download free fillable PDF (Portable Document Format) versions of Wisconsin workers’compensation forms courtesy Interface Technologies—http://www.interfacetec.com/
Wisconsin Compensation Rating Bureau—https://www.wcrb.org/WCRB/wcrbhome.htm Mailing Address: Post Office Box 3080 Milwaukee, WI 53201-3080 Street Address: 20700 Swenson Drive, Suite 100 Waukesha, Wisconsin 53186 (262) 796-4540, Fax: (262) 796-4400 Ralph M. Herrmann, President, [email protected]
Wisconsin Labor and Industry Review Commission—http://www.dwd.state.wi.us/lirc/ Mailing Address: Post Office Box 8126 Madison, Wisconsin 53708-8126 Street Address: Wisconsin Public Broadcasting Building 3319 West Beltline Highway Madison, Wisconsin (608) 266-9850 Fax: (608) 267-4409 E-mail: [email protected] David B. Falstad, Chairman Laurie R. McCallum, Commissioner James A. Rutkowski, Commissioner James L. Pflasterer, General Counsel
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Wyoming
State of Wyoming—http://wyoming.gov/ Department of Employment—http://wydoe.state.wy.us/ Cheyenne Business Center 1510 East Pershing Boulevard Cheyenne, Wyoming 82002 (307) 777-7672, Fax: (307) 777-5805 Gary W. Child, Director, (307) 777-5960, [email protected] Charles Rando, Administrator, (307) 777-6370,[email protected]
Workers’ Safety and Compensation Division—http://wydoe.state.wy.us/doe.asp?ID=9 Cheyenne Business Center 1510 East Pershing Boulevard Cheyenne, Wyoming 82002 (307) 777-7159, Fax: (307) 777-5524. To Report an Injury: (800) 870-8883 or (307) 777-7441, Fax: (307) 777-6552. To Report Fraud: (888) 996-9226or (307) 777-6552, Fax: (307) 777-3581. Steve Czoscke, Administrator, (307) 777-5110, Fax: (307) 777-5524, [email protected]
