WC-104A (12/20) - Application for Mediation or Hearing (fill-in form)
- The WC-104A may be completed online but must be printed and mailed to the agency for processing.
- After printing the form, please complete box #34 by circling either weekly or monthly where appropriate.
The form must be signed by at least the injured worker (or personal representative) or the attorney, preferably both. Unsigned forms will not be considered complete.
Forms not submitted properly will be returned.
To request a form to be sent in the mail, please call toll-free 1-888-396-5041 or email firstname.lastname@example.org.