2nd Injury Fund Forms

2021 Assessment

• 2021 2nd Injury Assessment and Report
  • PDF Format
• 2021 Certificate
  Please select the appropriate form below
  • Insurance Carrier
  • Self-Insured Employers

2020 2nd Injury Status Report

• PDF Format

2020 Assessment

• 2020 2nd Injury Assessment and Report
  • PDF Format
• 2020 Certificate
  Please select the appropriate form below
  • Insurance Carrier
  • Self-Insured Employers

2019 2nd Injury Status Report

• PDF Format

2019 Assessment

• 2019 2nd Injury Assessment and Report
  • PDF Format
• 2019 Certificate
  Please select the appropriate form below
  • Insurance Carrier
  • Self-Insured Employers

2018 2nd Injury Status Report

• PDF Format

2018 Assessment

• 2018 2nd Injury Assessment and Report
  • PDF Format
• 2018 Certificate
  Please select the appropriate form below
  • Insurance Carrier
  • Self-Insured Employers

2017 2nd Injury Status Report

• PDF Format

Injured Employee Assistance

• Application for Second Injury Fund Benefits

Prosthetic Applications

• Request for Prosthetic Repair or Replacement

Past Years Assessment Information