General Workers Compensation Forms
|Acord 130 Workers Compensation Application Form
The standard workers compensation insurance application for work comp and employers liability coverage.
*Form not applicable for Florida quotes.
|Acord 4 First Report of Injury Form
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.
|Workers Compensation Loss Affidavit
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.
|Workers Compensation Loss Runs Request Form
This form may be used to request loss runs from your current agent of record or insurance company.
|Agent of Record Change Request Form
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.
|Experience Mod Release Authorization Form
Complete this form in order to authorize NCCI to release your experience modification worksheets to our agency.
|Acord 35 Cancellation Request - Policy Release
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.
ERM 14 Form
ERM 14 Instructions
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.
Workers Comp Exemption Forms
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 right.
Injury Reports and Claim Forms
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.
Workers Compensation Waivers
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.
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