WC-701 (2/13) - Notice of Compensation Payments (fill-in form)

The copy of the WC-701 that is sent to the injured worker may be printed as a double-sided form and must be accompanied by a copy of WC-701 Filing Codes that lists the codes used on the front side of the WC-701.

If the form involves adjustments to PIWEC or coordination of benefits (e.g., pension, wage continuation, old age social security, unemployment, etc.), the document sent to the Workers' Compensation Agency must be printed as a double-sided form or it will be returned.

OCR Requirements:

Form WC-701 utilizes Optical Character Recognition (OCR) to scan data.  In order for the OCR function to work properly, a submitted form must be identical to the  WC-701 on the Workers' Compensation Agency website, including but not limited to language, block space and positioning, font and dimension.  When data is input into the form, Arial 10 point font must be used, with each field limited to one line of data.

Therefore, this form can't be handwritten and must be either mailed or submitted through the Data Exchange Gateway (DEG).  The DEG application provides further information.

Forms not complying with these requirements will be rejected and returned unprocessed.

 

  Click here for WC-701