GWC101a/b "Authorization for Medical Examination and/or Treatment"
Part A:  This side of the form should be completed in full and signed by the employer.  It authorizes a physician or a medical facility  to examine and/or treat the employee for the injuries arising out of such accidental occupational injury, illness, or disease covered by the Guam Worker's Compensation Law.
 
The injured worker may choose not to seek the initial treatment however this declination does not prohibit the worker to request such treatment in the future.  The employer issues the first authorization.  All subsequent authorizations are issued by the respective worker's compensation insurance carrier.
 
Part B:  INSTRUCTIONS TO PHYSICIAN:  This initial report should be completed and mailed within 20 days, the original to the Commissioner (see box 13 for address), with a copy to the Company's worker's compensation insurance carrier named in box 14.  Subsequent reports should be made regularly on this form or in a narrative form while employee is in your care. 
 
The physician's billing should be included with copies of Part A and B and forwarded to the insurance carrier named in box 14.

Click here to download form GWC101a/b

GWC201 "Notice of Employee's Injury, Illness or Death"
This form may be used by the Employee to file a notice of an injury, illness or in the case of death by Employee's representative.  No benefits can be paid without this notice.  Notice shall be given to the Commissioner and to the Employer by delivery or to the last known place of business.  A written statement by the injured worker or an in-house incident/accident report is also acceptable.  The worker may be contacted by this office should further information be needed. 

Click here to download form GWC201
 
GWC202 "Employer's Report of Occupational Injury or Illness"
This form may be used by the Employer to report an injury, illness or death.  22 GCA 9131 requires the Employer to report to the Commissioner within ten (10) days from the date of or knowledge of any injury, illness or death.  Failure or refusal to file this report may subject the Employer to a penalty of up to $500.00 for EACH failure or refusal to do so.

Click here to download form GWC202
 
GWC210 "Employer's Supplemental Report of Accident or Occupational Illness"
This report must be filed promptly with the Commissioner in every case in which (1) Form   GWC-202 does not show the date employee returned to work, and (2) each time an injured employee has returned to work but later becomes disabled for work.  If the employee is medically certified disabled for work, compensation payments should be reported by the insurance carrier on Forms GWC-206 and/or GWC-208.  Medical reports must be sent to the Commissioner promptly following first treatment and thereafter while treatment continues.

Click here to download form GWC210
 
* PLEASE PRINT LEGIBLY ON ALL FORMS *

22 GCA 9132 PENALTY FOR MISREPRESENTATION:  "Any person who wilfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or payment under this Title or for the purpose of evading liability for any benefit or payment under this Title shall be guilty of a misdemeanor and on conviction thereof shall be punished by a fine not to exceed one thousand dollars ($1,000.00), or by imprisonment not to exceed one (1) year, or both."