Informus - Form WCMT

Authorization Form For File Review or Release Of Copies
For The State of Montana
Workers' Compensation Claims File

I hereby authorize Informus acting as an agent for ___________________________________________ to review and/or receive copies from of any or all parts of the State of Montana's State Compensation Fund files(s). I understand this authorization will include release of information covering both pending and closed cases involving any work related injuries on file.

To be completed by EMPLOYER:


Date of request:___________________________________________

Signature of requester:___________________________________________

Employer's Full Name:___________________________________________

Employer's Street Address:___________________________________________

Employer's City, State and Zip Code:___________________________________________

To be completed by EMPLOYEE:


Employee's Social Security Number:___________________________________________

Employee's Date of Birth:___________________________________________

Employee's Full Name:___________________________________________

Employee's Street Address:___________________________________________

Employee's City, State and Zip Code:___________________________________________

Signature of Employee:___________________________________________

Note: This information is not to be used in a manner which would violate the Americans with Disabilities Act.

Informus Form-WCMT

Date of request:_____________________ Signature of requester:_ Employer's Full Name:_ Employer's Street Address:_ Employer's City, State and Zip Code:_______________________

Employee's Social Security Number:_____________________ Employee's Date of Birth:_ Employee's Full Name:_ Employee's Street Address:_ Employee's City, State and Zip Code:_ Signature of Employee:_____________________