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Labor and Economic Opportunity

Form FA 112 (8/19) - Application for Reimbursement

The Form 112 – Application for Reimbursement and supporting documentation may be submitted via upload through the File Transfer Service (FTS), a secure website portal.

Note: Form 112’s uploaded to the FTS are submitted to a different Mailbox than the Workers’ Disability Compensation Agency forms. If you already have a FTS account established, use Mailbox: WCFUNDSA and Application ID: 112FA when uploading the Form 112.

Those interested in participating that do not have a FTS User Account can email Diane Harger at An account will be established and the necessary instructions on how to upload the Form 112 via the FTS, including user ID, password, etc., will be provided.

Click for Form 112