We help business owners navigate Pennsylvania workers' comp rules.

We have compiled links for the most common downloadable forms, guides, and applications with regard to workers compensation in Pennsylvania. Our goal is keep our PA forms library up to date with the latest and most relevant information and helpful workers compensation forms.

If you need help completing a Pennsylvania form or have questions please contact one of our Workers Compensation Specialists.

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Pennsylvania Workers Compensation Insurance Forms

PA Acord 130 Workers Compensation Application

The standard Acord 130 application form for workers comp coverage in Pennsylvania.

Pennsylvania Required Online Submission Site for First Report of Injury

Employers should complete this online form to submit their claim each time an injury occurs.

Employers Application to Elect Domestic Employee Coverage Form

Complete this form to allow domestic employees to elect workers' compensation insurance.

Pennsylvania Workers Compensation Insurance Coverage Exemption Form

Workers' compensation exemption form to be completed by a Notary Public.

Affidavit of Exemption from the Workers' Compensation Act

Complete this form if you are not required to provide workers' compensation insurance under the provisions of Pennsylvania's Workers' Compensation Act.

Pennsylvania Officer Exemption Form

Application for executive officer exception from the provisions of the Pennsylvania workers' compensation act: section 104

Pennsylvania Notice of Insurance

Complete this form to register your insurance carrier with the state of Pennsylvania. for spousal exemptions.

Pennsylvania Workers' Compensation Notice of Temporary Compensation

Complete this form to register temporary compensation payments made by the employer when the claim is filed. Failure to complete this form shall be deemed an admission of liability.

Sole Proprietor's Voluntary Election of Coverage

Sole Proprietors electing to be covered under the Pennsylvania Workers’ Compensation Act must complete the Election of Coverage.

Pennsylvania Supplemental Agreement for Compensation for Disability or Permanent Injury

Complete this form to register supplemental compensation by the employer.

Workers' Comp Exemption

Each state has its own laws and requirements regarding when and how employers are allowed to opt-out of coverage under their workers compensation policy. Some states make it easier than others because they don't require anything to be filed. Other states require special inclusion or exclusion affidavit documentation. Failure to comply often causes employers to have to pay premium on themselves even when they wanted to be excluded form coverage.

Waiver of Subrogation

A waiver of subrogation means that a business and their insurance company is foregoing all rights to file suit, or seek damages, from another business. This is common in the construction industry as builders attempt to protect their company from negligence. A workers' comp waiver of subrogation does not prevent an injured employee from filing a lawsuit for damages. This coverage typically add about $100 to the cost of a work comp policy.

Certificate of Insurance

A Certificate of Insurance is a document that serves as evidence of insurance or proof of coverage. Certificates indicate your current coverages and policy limits. Insurance Agencies issue on an insured's behalf and they often list a third party as a certificate holder. This means they should be notified if a policy cancels prior to expiration. Requests for any special wording should be carefully checked against the policy language before being added to a certificate as they can create legal issues with coverage.


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State Resources for Pennsylvania

Pennsylvania Department of Labor and Industry

Room 1700
7th and Forster Streets
Harrisburg, PA 17120
717-787-5279
PA Dept of Labor

Pennsylvania Compensation Rating Bureau

United Plaza Building Ste 1500
30 South 17th Street
Philadelphia, PA 19103-4007
215-568-2371
DCRB/PCRB

Workers compensation insurance is required by law for Pennsylvania employers.

Pennsylvania and Delaware share a unique classification system separate from other NCCI states. The state also operates its own state workers compensation fund (SWIF) for employers who are unable to buy coverage from a private insurance carrier due to claims, losses, or industry class codes.

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Visit NCCI for more resources and information about workers' compensation class codes. Visit United States Department of Labor for more information about government agencies managing workers compensation insurance rates.

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