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The standard workers compensation insurance application for work comp and
employers liability coverage.
*Form not applicable for Florida
This form should be completed anytime an employee is inured on the job, or
claims to be injured. Employers are required to report all injury claims to
the insurance company within 7 business days from the 5th day of disability.
A workers comp loss affidavit should be completed by prospects seeking
coverage when they are unable to obtain official loss runs from their
insurance company or current agent of record.
This form may be used to request loss runs from your current agent of record
or insurance company.
Complete this form if you would like to change the agent of record from your
current agent or agency to Workers Compensation Shop/The Insurance Shop as
the agent on file with the carrier. This will enable us to service your
policy and work with the insurance company and NCCI on your behalf.
Complete this form in order to authorize NCCI to release your experience
modification worksheets to our agency.
Complete this form in order to officially cancel an active or renewal policy
with an existing insurance company. Most insurance carriers will continue to
charge premium until this form is returned to them.
Complete this form if there has been any change in ownership for any
existing workers comp policy. The form may be submitted to the rating
organization by the insured, agent, or insurance company.
Business owner and officer policy inclusion and exclusion rules are determined by
each state based on the laws and regulation of the state. Current workers
compensation Exemption Forms can be found by choosing your State Form Link to the
See Acord First Report of Injury Form above. Many states and insurance companies
also utilize the their own versions of Incident Report Forms. It is imperative that
employers report injuries directly to their insurance company or agent as close to
the accident as possible.
Waivers are not the same thing as Exemption Forms. Exemptions and Exclusions are for
businesses who have a policy in place for employees but need to elect or reject work
comp coverage for the owners and officers. Waivers are for business owners who do
not have employees and do not want to purchase coverage.
State rules will vary considerably regarding waivers. While a few states still allow
waivers, most states are requiring coverage for all businesses. Most notably,
contractors are now required to carry coverage regardless of not having employees.
Contact one of our Licensed Specialists at 888-611-7467 for the most current
rules and laws in your state.