- Application for Temporary Total Disability Benefits (PDF EN INGLÉS)
- Application for Temporary Total Disability Benefits-Extraordinary Circumstances (PDF EN INGLÉS)
- Change of Address Form (PDF EN INGLÉS)
- Change of Healthcare Provider Form (PDF EN INGLÉS)
- Light Duty Agreement (PDF EN INGLÉS)
- Reimbursement Voucher (PDF EN INGLÉS)
- U.S. Bank Reliacard Disclosures (PDF EN INGLÉS)
BROCHURES
- Injured Worker’s Guide to Reporting an Injury
- Information for Injured Workers
- Guía del solicitante de indemnización por accidente laboral
INJURED WORKER DEBIT CARD (RELIACARD®) INFORMATION
Injured workers receiving indemnity benefits as a result of their work-related injury, will automatically be enrolled to receive benefit payments via a US Bank Reliacard® debit card. If the injured worker would like to change the payment option to direct deposit of a financial institution of their choice, please contact the assigned claims analyst or (307) 777-7441 to begin the process.
- ReliaCard® Enrollment Form (PDF EN INGLÉS)
- ReliaCard® FAQs (PDF EN INGLÉS)
- ReliaCard® Debit Card Disclosure (PDF EN INGLÉS)
PROVIDER INJURED WORKER EMPLOYER RESOURCE SYSTEM (PIERS)
En Provider, Injured Worker, and Employer Resource System (PIERS) can be used to find claim information, billing status, payment, and benefit information.