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Workers Comp Forms for PA

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Pennsylvania Workers Comp Forms

Find Pennsylvania workers compensation forms and coverage guides.

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.

Call us today at 888-611-7467 or get started on PA quotes with one or more of our 35 insurance carriers.

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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.



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Pennsylvania Posting Notice

Employers in Pennsylvania are required by law to post an employee notice for workers' compensation insurance. The notice must be posted in a conspicuous place at each work location and it must include the name, address, and telephone number for the insurance company providing workers compensation coverage for the insured. Employers may post LIBC-500 or a similar document.

In most cases your insurance company will send your posting notice along with a copy of your insurance policy once your coverage is bound.


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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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We've developed Target Programs with our insurance companies to help find you the right insurance product with lower rates.


Learn more about workers compensation insurance in Pennsylvania Work Comp:   Pennsylvania | PA Programs| PA Rates | PA Forms | PA Info | PA Quotes
Workers Compensation Agents You Deserve Lower Rates.

A lot of business owners assume that workers comp rates are similar from one insurance company to the next. The fact is the cost of coverage will vary dramatically depending on the insurance companies loss ratio and experience within any given industry. We track rates for all our carriers so you get the best prices on coverage for your particular industry.

Give one of our Pennsylvania workers compensation Specialists a call today at 888-611-7467 for a free, no-obligation workers compensation insurance quote in Pennsylvania.

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