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Claim Forms

Please note: the Employee and Physician's Report of Injury Form is no longer available on the BrickStreet Web site. You can download the form from the West Virginia Offices of the Insurance Commissioner's website.

Change of Address Notification
BI-CANUse SHIFT+ENTER to open the menu (new window).
Claimant Travel Voucher
BI-102Use SHIFT+ENTER to open the menu (new window).
First Fill Form English-Spanish
First Fill Form English-SpanishUse SHIFT+ENTER to open the menu (new window).
Medical Records Release
Medical Records ReleaseUse SHIFT+ENTER to open the menu (new window).
Pharmacy Invoice
BI-401Use SHIFT+ENTER to open the menu (new window).
Request for Change of Physician
BI-RCPUse SHIFT+ENTER to open the menu (new window).
Request for File Copies
BI-910Use SHIFT+ENTER to open the menu (new window).


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