Alabama

State of Alabamahttp://www.al.gov/ Department of Industrial Relationshttp://dir.alabama.gov/ Phyllis Kennedy, Director, (334) 242-8990, Fax: (334) 242-3960, Director@dir.state.al.us Donald K. Fisher, Assistant Director, (334) 242-8990, Fax: (334) 242-3960, DFisher@dir.state.al.us Workers Compensation Divisionhttp://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) 3530990, Fax: (334) 353-8262, WC@dir.state.al.us Return to top of page

Alaska
State of Alaskahttp://www.state.ak.us/ Department of Labor and Workforce Development http://www.labor.state.ak.us/home.htm Workers Compensation Divisionhttp://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, Paul_Grossi@labor.state.ak.us Mark R. Torgerson, Chief of Adjudications, (907) 269-4982, mark_torgerson@labor.state.ak.us 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 Commissioner_Labor@labor.state.ak.us 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 Return to top of page

Arizona
State of Arizonahttp://www.state.az.us/ Industrial Commission of Arizonahttp://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 workerscompensation 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 Return to top of page

Arkansas
State of Arkansashttp://www.state.ar.us/ Workers Compensation Commissionhttp://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, breeves@awcc.state.ar.us Karen H. McKinney, Commissioner, kmckinney@awcc.state.ar.us Shelby W. Terry Turner, Commissioner,tturner@awcc.state.ar.us Alan McClain, Chief Executive Officer, amcclain@awcc.state.ar.us James W. Daniel, Assistant Chief Executive Officer, jdaniel@awcc.state.ar.us David Greenbaum, Chief Administrative Law Judge, dgreenbaum@awcc.state.ar.us Return to top of page

California
State of Californiahttp://www.ca.gov/ Department of Industrial Relationshttp://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: chswc@hq.dir.ca.gov 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 DarrelShorty 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: dwc@dir.ca.gov Rosa Moran, Administrative Director Keven Star, Court Administrator Click here to download free fillable PDF (Portable Document Format) versions of California workerscompensation 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) 9991041 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. OBrien, 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: SIP@dir.ca.gov 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 Return to top of page

Colorado
State of Coloradohttp://www.colorado.gov/ Department of Labor & Employmenthttp://www.coworkforce.com/ 633 17th Street, Suite 200 Denver, Colorado 80202-3660 Donald J. Mares, Executive Director, (303) 318-8020 Division of Workers Compensationhttp://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: workers.comp@state.co.us 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 workerscompensation 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 Return to top of page

Connecticut
State of Connecticuthttp://www.ct.gov/ Workers Compensation Commissionhttp://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) 2471361 wcc.chairmansoffice@po.state.ct.us 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 workerscompensation forms courtesy Interface Technologieshttp://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 Return to top of page

Delaware
State of Delawarehttp://delaware.gov/ Department of Laborhttp://www.delawareworks.com/ 4425 North Market Street Wilmington, Delaware 19802 dlabor@state.de.us 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, john.kirk@state.de.us 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 Return to top of page

District of Columbia
District of Columbiahttp://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: does@dc.gov 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

Return to top of page

Florida
State of Floridahttp://www.myflorida.com/ Florida Department of Financial Serviceshttp://www.myfloridacfo.com/ Alex Sink, Chief Financial Officer, Alex.Sink@myfloridacfo.com 200 East Gaines Street Tallahassee, FL 32399-0300 (850) 413-3100, Consumer Helpline: (800) 342-2762 Division of Workers Compensationhttp://www.myfloridacfo.com/WC/ 200 East Gaines Street Tallahassee, Florida 32399-4220 (850) 413-1609; Fax: (850) 922-6779; Injured Worker Helpline: (800) 7422214; 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: Workers.CompService@MyFloridaCFO.com Tanner Holloman, Director, (850) 4882514,Tanner.Holloman@myfloridacfo.com Andrew Sabolic, Assistant Director, Andrew.Sabolic@myfloridacfo.com Click here to download free fillable PDF (Portable Document Format) versions of Florida workerscompensation 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, Claudia_Llado@doah.state.fl.us Office of Judges of Compensation Claimshttp://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 Educationhttp://www.fldoe.org/ Florida Division of Vocational Rehabilitationhttp://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 Return to top of page

Georgia
State of Georgiahttp://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 workerscompensation 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, mcoan@sitf.ga.gov Allan Payne, Deputy Administrator, (404) 656-7062, apayne@sitf.ga.gov

Kathy Cannon, Director of Administrative Services, (404) 656-7022, kcannon@sitf.ga.gov Return to top of page

Hawaii
State of Hawaiihttp://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, dlir.director@hawaii.gov 830 Punchbowl Street Honolulu, Hawaii 96813 (808) 586-8842, Fax: (808) 586-9099, dlir.director@hawaii.gov Disability Compensation Divisionhttp://hawaii.gov/labor/dcd/index.shtml 830 Punchbowl Street, #211 Honolulu, Hawaii 96813 (808) 586-9151, Fax: (808) 586-9219, dlir.workcomp@hawaii.gov Gary Hamada, Administrator Labor & Industrial Relations Appeals Board http://hawaii.gov/labor/hlirab/index.shtml 830 Punchbowl Street #404 Honolulu, Hawaii 96813 (808) 586-8600, Fax: (808) 586-8599, dlir.laborboard@hawaii.gov Randall Iwase, Chairman Return to top of page

Idaho
State of Idahohttp://www.idaho.gov/ Idaho Industrial Commissionhttp://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, nbeeson@iic.idaho.gov State Insurance Fundhttp://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: Claims@isif.state.id.us Customer Service Center: CustomerService@isif.state.id.us Fraud: Claims@isif.state.id.us General Information/News Media Inquiries: abunch@isif.state.id.us Management Services: ManagementServices@isif.state.id.us Managers Office: Administration@isif.state..id.us Policyholder Services: PHS@isif.state.id.us Underwriting: Underwriting@isif.state.id.us Return to top of page

Illinois
State of Illinoishttp://www.il.gov/ Illinois Workers Compensation Commissionhttp://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: infoquestions.wcc@illinois.gov Commissioners Mitch Weisz, Chairman, (312) 814-6560, nicholas.velazquez@illinois.gov Mario Basurto, Commissioner, (312) 814-5641, marcia.monroe@illinois.gov Yolaine Dauphin, Commissioner, (312) 814-1110, serina.jenkins@illinois.gov James F. DeMunno, Commissioner, (312) 814-6606, joanne.cozzo@illinois.gov

Dan Donohoo, Commissioner, (312) 814-6058, wayland.johnson@illinois.gov David Gore, Commissioner, (312) 814-1211, gina.a.logalbo@illinois.gov Kevin Lamborn, Commissioner, (312) 814-1522, vivian.frederick@illinois.gov Nancy Lindsay, Commissioner, (312) 814-1157, loretta.jackson@illinois.gov Molly Mason, Commissioner, (312) 814-6601, barbara.galazkiewicz@illinois.gov Thomas Tyrrell, Commissioner, (312) 814-6603, yvonne.laws@illinois.gov Administrator Kimberly Janas, Secretary of the Commission/Chief of Staff, (312) 814-6559, kimberly.janas@illinois.gov 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 workerscompensation forms courtesy Interface Technologies http://www.interfacetec.com/ Illinois Workers Compensation Commission Office of Self-Insurance Administrationhttp://www.iwcc.il.gov/selfinsurance.htm E-mail: jean.cannon@illinois.gov Maria Sarli-Dehlin, Manager of Self-Insurance,(312) 814-6065, maria.dehlin@illinois.gov 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 Return to top of page

Indiana
State of Indianahttp://www.in.gov/ Workers Compensation Board of Indianahttp://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) 2325922 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: icrb@icrb.net Ronald W. Cooper, CWCP, President, rcooper@icrb.net Return to top of page

Iowa
State of Iowahttp://www.iowa.gov/ Iowa Workforce Developmenthttp://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

E-mail: IWD.DWC@iwd.iowa.gov Christopher J. Godfrey, Workers Compensation Commissioner, Christopher.Godfrey@iwd.iowa.gov Janna E. Polite, Assistant Workers' Compensation Commissioner, Janna.Polite@iwd.iowa.gov Sharon K. Ortega, Administrative Secretary, Sharon.Ortega@iwd.iowa.gov Return to top of page

Kansas
State of Kansashttp://www.kansas.gov/ Department of Laborhttp://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) 3320353, (785) 296-6392; Industrial Safety & Health: (800) 332-0353, (785) 2964386; Ombudsman: (800) 332-0353, (785) 296-2996 Paula Greathouse, Director, (785) 296-2996 Return to top of page

Kentucky
Commonwealth of Kentuckyhttp://kentucky.gov/ Kentucky Department of Laborhttp://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 Claimshttp://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 workerscompensation 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 Commissionhttp://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; Gordon.Stammel@ky.gov Kentucky Workers Compensation Law (via CompEd, Inc.) http://www.comped.net/ Return to top of page

Louisiana
State of Louisianahttp://www.louisiana.gov/wps/portal/ Department of Laborhttp://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 WCFraud@ldol.state.la.us, Safety:(800) 201-2497 E-mail: OWCA@ldol.state.la.us Karen Reiners Winfrey, Assistant Secretary of Labor Return to top of page

Maine

State of Mainehttp://www.maine.gov/ Workers Compensation Boardhttp://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, steven.minkowsky@maine.gov Elizabeth Inman, Deputy Director, Office of Medical Rehabilitation Services,(207) 941-4557, betty.inman@maine.gov John Rohde, General Counsel, (207) 287-7086 Click here to download free fillable PDF (Portable Document Format) versions of Maine workerscompensation forms courtesy Interface Technologies http://www.interfacetec.com/ Return to top of page

Maryland
State of Marylandhttp://www.maryland.gov/ Workers Compensation Commissionhttp://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) 8464069;info@wcc.state.md.us 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 workerscompensation forms courtesy Interface Technologies http://www.interfacetec.com/ Insured Workers Insurance Fundhttp://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), reportfraud@iwif.com 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 Return to top of page

Massachusetts
Commonwealth of Massachusettshttp://www.mass.gov/ Department of Industrial Accidentshttp://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 workerscompensation forms courtesy Interface Technologieshttp://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 WorkersCompensation 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 Return to top of page

Michigan

State of Michiganhttp://www.michigan.gov/ Department ofLabor & Economic Growthhttp://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 Agencyhttp://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: wcinfo@michigan.gov Kevin A. Elsenheimer, Director, (517) 322-1106, Fax: (517) 322-6689, elsenheimerk@michigan.gov Jack A. Nolish, Deputy Director, (517) 322-1106, Fax: (517) 322-6689, nolishj@michigan.gov Sue Bickel, Secretary, (517) 322-1106, Fax: (517) 322-6689, sbicke@michigan.gov Click here to download free fillable PDF (Portable Document Format) versions of Michigan workerscompensation forms courtesy Interface Technologies http://www.interfacetec.com/ Board of Magistrateshttp://www.michigan.gov/wca/0,1607,7-191-26919--,00.html Post Office Box 30016 Lansing, Michigan 48909 (517) 241-9380, Fax: (517) 241-9379, TDD in Lansing: (517) 322-5987 Murray Gorchow, Acting Chairman, (313) 456-3657, Fax: (313) 456-3651, magorch@michigan.gov

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:wcacinfo@michigan.gov Martha M. Glaser, Chairperson James J. Kent Gregory A. Przybylo Granner S. Ries Rodger G. Will Michigan Economic Development Corporationhttp://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 Return to top of page

Minnesota
State of Minnesotahttp://www.mn.gov/ Department of Labor and Industryhttp://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 Divisionhttp://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: DLI.Workcomp@state.mn.us Beth Hargarten, Assistant Commissioner Click here to download free fillable PDF (Portable Document Format) versions of Minnesota workerscompensation 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 Return to top of page

Mississippi
State of Mississippihttp://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, lwilliams@mwcc.state.ms.us Debra Gibbs, Commissioner, (601) 987-4254, dgibbs@mwcc.state.ms.us John Junkin, Commissioner, (601) 987-4254, jjunkin@mwcc.state.ms.us Ray C. Minor, Executive Director, (601) 987-4205, rminor@mwcc.state.ms.us Phyllis Clark, Commission Secretary, (601) 987-4252, pclark@mwcc.state.ms.us Return to top of page

Missouri
State of Missourihttp://www.mo.gov/ Department of Labor and Industrial Relationshttp://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, Email: Diroffice@dolir.mo.gov

Division of Workers Compensationhttp://www.labor.mo.gov/DWC/ Street Address: 3315 West Truman Boulevard, Room 131 Jefferson City, Missouri 65102

Mailing Address: Post Office Box 58 Jefferson City, Missouri 65102-0058 (573) 751-4231, Fax: (573) 751-2012, Employee Hotline: (800) 775-2667, Employer Hotline: (888) 837-6069, Fraud and Noncompliance: (800)-592-6003, (573)-526-6630, Workers Safety Program: (573) 526-3504 E-mail: Workerscomp@dolir.mo.gov Brian May, Director, (573) 751-4231, Fax: (573) 751-2012 Click here to download free fillable PDF (Portable Document Format) versions of Missouri workers compensation forms courtesy Interface Technologies http://www.interfacetec.com/

Labor and Industrial Relations Commissionhttp://www.labor.mo.gov/LIRC/ Street Address: 3315 West Truman Boulevard Jefferson City, Missouri 65102 Mailing Address: Post Office Box 599 Jefferson City, Missouri 65102-0599 (573) 751-2461, Fax: (573) 751-7806, E-Mail: lirc@labor.mo.gov William F. Ringer, Chairman Alice A. Bartlett, Commissioner John J. Hickey, Commissioner Pamela M. Hofmann, Secretary

Return to top of page

Montana
State of Montanahttp://mt.gov/ Department of Labor and Industryhttp://dli.mt.gov/ Post Office Box 1728 Helena, Montana 59624-1728 (406) 444-2840, Fax: (406) 444-1394 E-mail: dliquestions@mt.gov Keith Kelley, Commissioner

Employment Relations Divisionhttp://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

Workers Compensation Claims Assistance Bureau http://erd.dli.mt.gov/wcca-bureau.html Street Address: 1805 Prospect Avenue Helena, Montana 59624 Mailing Address: Post Office Box 8011 Helena, Montana 59624-8011 (406) 444-6543, Fax: (406) 444-3465, TDD: (406) 444-9696 E-mail: jakoehl@mt.gov Diana Ferriter, Bureau Chief, (406) 444-6543, diferriter@mt.gov Workers Compensation Regulations Bureau http://erd.dli.mt.gov/workers-comp-regulations-bureau.html Street Address: 1805 Prospect Avenue Helena, Montana 59624 Mailing Address: Post Office Box 8011 Helena, Montana 59624-8011 (406) 444-6541, Fax: (406) 444-3465 Connie Ferriter, Acting Bureau Chief, (406) 444-6541
Workers Compensation Courthttp://wcc.dli.mt.gov/ Street Address: 1625 11th Avenue Helena, Montana Mailing Address: Post Office Box 537 Helena, Montana 59624-0537 (406) 444-7794, Fax: (406) 444-7798

E-mail: pkessner@state.mt.us James Jeremiah Shea, Judge

Montana State Fundhttp://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, mtguarantyfund@mt.net Jeff Lapham, Executive Director Return to top of page

Nebraska
State of Nebraskahttp://www.nebraska.gov/ Workers Compensation Courthttp://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

Glenn W. Morton, Administrator, (402) 471-3602, Fax: (402) 471-2700, glenn.morton@wcc.ne.gov Return to top of page

Nevada
State of Nevadahttp://www.nv.gov/ Department of Business & Industryhttp://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: biinfo@dbi.state.nv.us In Southern Nevada: 555 E. Washington Avenue, Suite 4900 Las Vegas, Nevada 89101 (702) 486-2750, Fax: (702) 486-2758 E-Mail: biinfo@dbi.state.nv.us

Division of Industrial Relationshttp://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) 6876305, rbremner@dbi.state.nv.us John Laxalt, Assistant Administrator, (775) 684-7263, Fax: (775) 6876305, jplaxalt@dbi.state.nv.us

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: wcshelp@dbi.state.nv.us Charles J. Verre, Chief Administrative Officer, (702) 486-9087, cverre@dbi.state.nv.us Northern District: 400 West King Street, Suite 400 Carson City, Nevada 89703 (775) 684-7270, Fax: (775) 687-6305 Charlotte LaCombe, (775) 684-7278, clacombe@dbi.state.nv.us 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, kwebb@dbi.state.nv.us Nevada Attorney for Injured Workershttp://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: naiw@naiw.nv.gov Gary Watson, Supervising Attorney 1000 East William Street, Suite 208 Carson City, Nevada 89701 (775) 684-7555, Fax: (775) 684-7575 E-mail: naiw@naiw.nv.gov Donna Sweger, Supervising Attorney
EMPLOYERS Insurancehttp://www.employers.com 10375 Professional Circle Reno, Nevada 89521-4802 Customer Service: (888) 682-6671, Fax: (888) 527-3422, Email:renoinfo@employers.com; Fraud Hotline: (800) 750-3939, E-mail: fraudunit@employers.com; Loss Control: (800) 5885200;losscontrol@employers.com; Audit/Collections: (800) 677-3252, Email:customersupport@employers.com.

Douglas D. Dirks, President and Chief Executive Officer of Employers Holdings, Inc. Return to top of page

New Hampshire
State of New Hampshirehttp://www.nh.gov/ Department of Laborhttp://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 (selfinsurance), (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 workerscompensation forms courtesy Interface Technologieshttp://www.interfacetec.com/ Return to top of page

New Jersey
State of New Jerseyhttp://www.nj.gov/ Department of Laborhttp://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: dwc@dol.state.nj.us Peter Calderone, Chief Judge & Director, (609) 292-2414, fax: (609) 9842515,peter.calderone@dol.state.nj.us Renee Ricciardelli, Administrative Supervising Judge, (609) 292-2414, fax: (609) 984-2515, renee.ricciardelli@dol.state.nj.us Click here to download free fillable PDF (Portable Document Format) versions of New Jersey workerscompensation forms courtesy Interface Technologieshttp://www.interfacetec.com/ N.J. Compensation Rating and Inspection Bureauhttp://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 Return to top of page

New Mexico
State of New Mexicohttp://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: wca.hotline@state.nm.us

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) 8416004,Van.Cravens@state.nm.us 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 Return to top of page

New York
State of New Yorkhttp://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: general_information@wcb.state.ny.us 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 workerscompensation forms courtesy Interface Technologies http://www.interfacetec.com/ New York State Insurance Fundhttp://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 Return to top of page

North Carolina
State of North Carolinahttp://www.ncgov.com/ Department of Commercehttp://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: info@nccommerce.com J. Keith Crisco, Secretary

North Carolina Industrial Commissionhttp://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, InfoSpec@ic.nc.gov, Fraud: fraudcomplaints@ic.nc.gov, Safety: safety@ic.nc.gov Pamela T. Young, Chair,(919) 807-2517, Pamela.Young@ic.nc.gov Bernadine S. Ballance, Commissioner, (919) 807-2511, Bernadine.Ballance@ic.nc.gov Linda Cheatham, Commissioner, (919) 807-2523, Linda.Cheatham@ic.nc.gov Danny Lee McDonald, Commissioner,(919) 807-2516, Danny.McDonald@ic.nc.gov Staci T. Meyer, Commissioner, (919) 807-2525, Staci.Meyer@ic.nc.gov Tammy R. Nance, Commissioner, (919) 807-2525, Tammy.Nance@ic.nc.gov Christopher Scott, Commissioner,(919) 807-2513, Chris.Scott@ic.nc.gov Barbara Levine, Administrator,(919) 807-2525, Barbara.Levine@ic.nc.gov Fraud Investigations Section: (888) 891-4895 (in North Carolina), fraudcomplaints@ic.nc.govhttp://www.ic.nc.gov/fraud.html Safety Education Section: (919) 807-2603, safety@ic.nc.gov http://www.ic.nc.gov/safety.html Workers Compensation Information Specialists Section (formerly Ombudsman Section): (800) 688-8349, InfoSpec@ic.nc.gov http://www.ic.nc.gov/infospec.html Click here to download free fillable PDF (Portable Document Format) versions of North Carolina workerscompensation forms courtesy Interface Technologieshttp://www.interfacetec.com/ Return to top of page

North Dakota
State of North Dakotahttp://www.nd.gov/ Workforce Safety & Insurancehttp://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: WorkforceSafety@wcb.state.nd.us 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. Return to top of page

Ohio
State of Ohiohttp://ohio.gov/ Ohio Bureau of Workers Compensationhttp://www.ohiobwc.com/ 30 West Spring Street Columbus, Ohio 43215-2256 E-mail: Feedback@bwc.state.oh.us (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, Ombudsperson@bwc.state.us.us Marsha P. Ryan, Administrator Click here to download free fillable PDF (Portable Document Format) versions of Ohio workerscompensation forms courtesy Interface Technologies http://www.interfacetec.com/ Industrial Commission of Ohiohttp://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 Return to top of page

Oklahoma
State of Oklahomahttp://www.ok.gov/ Oklahoma Workers Compensation Courthttp://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) 5812714 (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 Laborhttp://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) 5285751; lfields@oklaosf.state.ok.us Workers Compensation Enforcement Unit http://www.okdol.state.ok.us/workcomp/index.htm

Sharon Eischen, Director, seischen@oklaosf.state.ok.us Worker Safety Policy Councilhttp://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 Oklahomahttp://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) 8727015; Claims Information: (800) 462-7966, (405) 962-3872; Fax: (405) 9623000, Fraud Hotline:(800) 899-1847 Claims Information: claims@compsourceok.com, Fraud: fraud@compsourceok.com 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) 9623127,janet_m@compsourceok.com Davina Craig-Sealock, Executive Secretary, (405) 962-3294, Fax: (405) 9623127, davina_c@compsourceok.com Lisa Blodgett, General Counsel,(405) 962-3811, Fax: (405) 962-3048, lisa_b@compsourceok.com 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 Return to top of page

Oregon
State of Oregonhttp://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,DCBS.Director@state.or.us Greg Malkasian, Deputy Director, (503) 378-4100, Fax: (503) 3786444,Gregory.A.Malkasian@state.or.us Workers Compensation Divisionhttp://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,

John.L.Shilts@state.or.us Jerry Managhan, Deputy Administrator, (503) 947-7501, managhjr@cbs.state.or.us 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 ORourke, 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,louis.d.savage@state.or.us 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 Maria.A.Carraher@state.or.us

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 John.R.Booton@state.or.us SAIF Corporationhttp://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 Return to top of page

Pennsylvania
State of Pennsylvaniahttp://www.pa.gov/portal/server.pt Department of Labor and Industryhttp://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: ra-li-bwc-helpline@state.pa.us John T. Jack Kupchinsky, Director,jkupchinsk@state.pa.us Click here to download free fillable PDF (Portable Document Format) versions of Pennsylvania workerscompensation forms courtesy Interface Technologieshttp://www.interfacetec.com/ State Workers Insurance Fund http://www.dli.state.pa.us/landi/cwp/view.asp?a=151&q=209835 Street Address

100 Lackawanna Avenue Scranton, Pennsylvania 18503 Mailing Address Post Office Box 5100 Scranton, Pennsylvania 18505-5100 (570) 963-4635 E-mail: ra-li-e-mail-swif@state.pa.us Marisue Newman, Director 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. ONeal, Commissioner Joseph T. Rafferty, Commissioner Joseph P. Santone, Commissioner John J. Schmitt, Commissioner Harry Schwartz, Commissioner Delores Wilson, Commissioner Return to top of page

Rhode Island
State of Rhode Islandhttp://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.,ghealy@courts.state.ri.us

Jannette A. Bertness, Judge, jbertness@courts.state.ri.us Dianne M. Connor, Judge,dconnor@courts.state.ri.us Bruce Q. Morin, Judge,bmorin@courts.state.ri.us Debra L. Olsson, Judge,dolsson@courts.state.ri.us Hugo L. Ricci, Jr., Judge,hricci@courts.state.ri.us John Rotondi, Jr., Judge, jrotondi@courts.state.ri.us George T. Salem, Jr., Judge,gsalem@courts.state.ri.us Edward P. Sowa, Jr., Judge,esowa@courts.state.ri.us Dennis I. Revens, Administrator, drevens@courts.state.ri.us Kenneth D. Haupt, Deputy Administrator, khaupt@courts.state.ri.us 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, MAveno@courts.state.ri.us Workers Compensation Advisory Council 194 Smith Street Providence, Rhode Island 02908 (401) 751-7100 George Nee, Chairperson Department of Labor and Traininghttp://www.dlt.ri.gov/ 1511 Pontiac Avenue Cranston, Rhode Island 02920-4407 (401) 462-8000 Adelita S. Orefice, Director, AOrefice@DLT.state.ri.us Workers Compensation Divisionhttp://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, JSeverance@DLT.state.ri.us Matthew P. Carey, III, Assistant Director, (401) 462-8127,

MCarey@DLT.state.ri.us Click here to download free fillable PDF (Portable Document Format) versions of Rhode Island workerscompensation forms courtesy Interface Technologieshttp://www.interfacetec.com/ Return to top of page

South Carolina
State of South Carolinahttp://www.sc.gov/ Workers Compensation Commissionhttp://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) 7375764 Derrick L. Williams, Commissioner, (803) 737-5700, Fax: (803) 737-5764 Gary R. Thibault, Executive Director, (803) 737-5744, Fax: (803) 737-5764, gthibault@wcc.sc.gov Click here to download free fillable PDF (Portable Document Format) versions of South Carolina workerscompensation forms courtesy Interface Technologieshttp://www.interfacetec.com/ South Carolina State Accident Fundhttp://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, pparker@scsn.net

South Carolina Second Injury Fundhttp://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 Associationhttp://www.scselfinsurers.com/ 215 Holly Ridge Lane West Columbia, SC 29169 (803) 794-2080, Fax: (803) 939-8366 Mobashir Moby Salahuddin, Executive Director, msalahuddin@sc.rr.com 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

Return to top of page

South Dakota
State of South Dakotahttp://www.sd.gov/ Department of Laborhttp://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: labor@dol-pr.state.sd.us (605) 773-3681, Fax: (605) 773-4211 James Marsh, Director Workers Compensation Advisory Council http://dol.sd.gov/workerscomp/advisorycouncil.aspx Dennis Daugaard, Chair Return to top of page

Tennessee
State of Tennesseehttp://www.tennessee.gov/ Department of Labor and Workforce Development http://www.tennessee.gov/labor-wfd/ Workers Compensation Divisionhttp://www.state.tn.us/laborwfd/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 workerscompensation forms courtesy Interface Technologies http://www.interfacetec.com/ Return to top of page

Texas
State of Texashttp://www.state.tx.us/ Department of Insurancehttp://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; Commissioners 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: WorkersCompCustomerServices@tdi.state.tx.us 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. Return to top of page

Utah
State of Utahhttp://www.utah.gov/ Labor Commissionhttp://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 iaccd@utah.gov R. Lee Ellertson, Chairman Thomas R. Carlson, Commissioner Colleen S. Colton, Commissioner Larry D. Bunkall, Director, (801) 530-6988, Fax: (801) 530-6804, lbunkall@utah.gov 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 Return to top of page

Vermont
State of Vermonthttp://vermont.gov/ Department of Laborhttp://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, pmcdonald@labor.state.vt.us

Workers Compensation & Safety Division http://labor.vermont.gov/Business/WorkersCompensation/tabid/114/Defa ult.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, stephen.monahan@state.vt.us Rebecca Smith, Staff Attorney, (802) 828-2992, rebecca.smith@state.vt.us Kristina Bielenberg, Supervisor, (802) 8282286,kristina.bielenberg@labor.state.vt.us Click here to download free fillable PDF (Portable Document Format) versions of Vermont workerscompensation forms courtesy Interface Technologies http://www.interfacetec.com/ Return to top of page

Virginia
Commonwealth of Virginiahttp://www.virginia.gov/ Virginia Workers Compensation Commissionhttp://www.vwc.state.va.us 1000 DMV Drive Richmond, Virginia 23220 (877) 664-2566, Fax: (804) 367-9740, TDD: (804) 367-8600 E-mail: Questions@vwc.state.va.us 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 workerscompensation forms courtesy Interface Technologies http://www.interfacetec.com/

Return to top of page

Washington
State of Washingtonhttp://access.wa.gov/ Department of Labor and Industrieshttp://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 Appealshttp://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 workerscompensation forms courtesy Interface Technologieshttp://www.interfacetec.com/ Return to top of page

West Virginia
West Virginiahttp://www.wv.gov/ Insurance Commissionhttp://www.wvinsurance.gov/ Jane L. Cline, Commissioner BrickStreet Mutual Insurance Companyhttp://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: ClaimsInquiries@brickstreet.com; Fraud:reportfraud@brickstreet.com; Insurance: (866) 45BRICK (452-7425) and (304) 941-1000, Fax: (304) 304-941-1151; Providers: ProviderInquiries@brickstreet.com; Safety Services: SafetyServicesInquiries@brickstreet.com Gregory A. Burton, President and Chief Executive Officer, (304) 926-5060, greg.burton@brickstreet.com 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 WorkersCompensation Office of Judgeshttp://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 WorkersCompensation 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 Return to top of page

Wisconsin
State of Wisconsinhttp://www.wisconsin.gov/state/home Department of Workforce Developmenthttp://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, frances.huntleycooper@dwd.state.wi.us John Conway, Deputy Administrator, (608) 266-0337,

conwajo@dwd.state.wi.us Jean Culbert, Administrative Support, (608) 266-6898, culbeje@dwd.state.wi.us Click here to download free fillable PDF (Portable Document Format) versions of Wisconsin workerscompensation forms courtesy Interface Technologies http://www.interfacetec.com/ Workers Compensation Advisory Council http://www.dwd.state.wi.us/wc/councils/wcac/default.htm (608) 266-6841 Frances Huntley-Cooper, Chairman 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, herrmra@dwd.state.wi.us 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: dwdlirc@dwd.state.wi.us David B. Falstad, Chairman Laurie R. McCallum, Commissioner James A. Rutkowski, Commissioner James L. Pflasterer, General Counsel Return to top of page

Wyoming
State of Wyominghttp://wyoming.gov/ Department of Employmenthttp://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, GCHILD@STATE.WY.US Charles Rando, Administrator, (307) 777-6370,CRANDO@state.wy.us 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, SCZOSC@STATE.WY.US Employment Tax Divisionhttp://wydoe.state.wy.us/doe.asp?ID=10 Post Office Box 2760 Casper, Wyoming 82602-2760 (307) 235-3201 (Casper) or (307) 777-7471 (Cheyenne) Wendy Tyson, Administrator, (307) 777-6763, wtyson@state.wy.us Return to top of page