Workers’ Compensation

Policy Forms & Endorsements

While some policy forms and endorsements are applicable on a countrywide basis, be sure to check the state-specific sections of this page for any exceptions.

Countrywide
ERM 14: Request for Ownership Information Form *
GUARD Request for Exclusion From WC Coverage Form *
GUARD Request for Inclusion of WC Coverage Form *
No Known Loss Certification *
Referral for Waiver of Subrogation Request *

Alaska
AK Form 54-1: Contracting Classification Premium Adjustment Program Credit *
AK Form 07-6131: Petition for Executive Officer Waiver *
AK Workers’ Comp Inclusion Form – Corporation *
AK Workers’ Comp Inclusion Form – Limited Liability Company Member *
AK Workers’ Comp Inclusion Form – Sole Proprietor/Partners *

Alabama
AL Drug-Free Workplace Premium Credit Application *
AL Drug-Free Workplace Premium Credit Application – Recertification *
AL Workers’ Compensation Fraud Poster *
AL Form WCC#1: Workers’ Compensation Posting Notice *
AL Notice of Election to Accept or Reject an Insurance Deductible *

Arkansas
AR Form HS-36-A: Application for Drug-Free Workplace Program *
AR Notice of Election to Accept or Reject an Insurance Deductible *

Arizona
AZ Workers’ Compensation Corporation Working Shareholder Inclusion Form *
AZ Workers’ Compensation Limited Liability Company Member Inclusion Form *
AZ Workers’ Compensation Sole Proprietor/Partners Inclusion Form *
AZ Form ICA 04-0113: Employee’s Notice of Rejection of Terms of Arizona WC Law *
AZ Form ICA 0114: Employee’s Notice to Revoke Rejection of Terms of AZ WC Law *
AZ Annual Drug & Alcohol Program Verification Form *

California
CA Cooperative Corporation Waiver of WC Coverage Form *
CA General Partners and LLC Members Waiver of WC Coverage Form *
CA Corporate Officers/Directors Waiver of Coverage Form *
CA Notification of Change in Ownership and/or Combinability of Entities; see below *
WCIRB Connect® Ownership Information Submission Tool | WCIRB California
CA Professional Corporation Waiver of WC Coverage Form *
CA Trusts Waiver of WC Coverage Form *
CA Election to Exclude Residing Relatives From WC Coverage Form *

Colorado
CO Notice of Election to Accept or Reject an Insurance Deductible *
CO Form WC43: Rejection of Coverage by Corporate Officers/Members of LLC *
CO Workers’ Comp Acknowledgement Form *

Connecticut
CT Drug-Free Workplace Program Form *
CT Form 6B: Coverage Election by Employee Who is an Officer or LLC Member *
CT Form 6B-1: Coverage Election by Employees Who are Members of a Partnership *
CT Form 75: Coverage Election by Sole Proprietor *
CT Contracting Classification Premium Adjustment Program Application *
CT Notice of Election to Accept or Reject an Insurance Deductible *

Delaware
DE DCRB Construction Classification Premium Credit Application *
DE Form DCRB-EXCL: Ex. Officer/LLC Member Not to be Subject to the DE WC Law*
DE Form WC G10701: Notice of Election to Accept or Reject an Insurance Deductible *

Florida
FL ACORD Form 130: Florida Workers’ Compensation Application *
FL Form 09-01A: Application for Drug-Free Workplace Premium Credit Program *
FL Form Safety 09-3A: Cert. of Employer Workplace Safety Program Premium Credit *
FL Form 09-4E: Contracting Classification Premium Credit Application *
FL Employer’s Guide to Drug-Free Workplace *
FL Form DWC 250: Notice of Election to be Exempt (required by the state to be completed online) *
FL Form DWC 250-R: Notice of Revocation of Election to be Exempt *
FL Form DWC 251: Notice of Election of Coverage *
FL Form DWC 251-R: Revocation of Election of Coverage *
FL Notice of Election to Accept or Reject Coinsurance *
FL Notice of Election to Accept or Reject a Deductible *

Georgia
GA Notice of Election to Accept or Reject an Insurance Deductible *
GA Form WC 10: Notice of Election or Rejection of WC Coverage *
GA Application for Drug-Free Workplace Premium Credit Program *

Hawaii
HI Notice of Election to Accept or Reject an Insurance Deductible *
HI Contracting Classification Premium Adjustment Credit Application *

Iowa
IA Form 14-0061: Exclusion from WC Coverage (required by the state to be completed online) *
IA Form 14-0175: Non-Election of WC Coverage (required by the state to be completed online) *

Idaho
ID Drug-Free Workplace Program Form *
ID Form IC52: Election of Coverage *

Illinois
IL Civil Unions and Insurance Benefits *
IL Contracting Classification Premium Adjustment Program Credit Application *
IL Notice of Election to Accept or Reject An Insurance Deductible *

Indiana
IN Notice of Election to Accept or Reject an Insurance Deductible *
IN Form 36097: Notice for WC & Occupational Diseases – Exclusion/Election *

Kansas
KS Form K-WC 50: Election of Employee Not to Accept Coverage *
KS Form K-WC 50-A: Cancellation of Form K-WC 50 *
KS Form K-WC 113: Election of Individual to Come Under Act *
KS Form K-WC 114: Cancellation of Form K-WC 113 *

Kentucky
KY Application for Certification of Drug-Free Workplace Program *
KY Form 4: Notice of Rejection – Original is needed; see instructions below
KY Form 5: Written Notice of Withdrawal – Original is needed; see instructions below
[Instructions: Policyholder’s agent should e-mail laborkywccompliance@ky.gov (primary contact method) or call 502-782-4525 (secondary). Provide the business name, mailing address, phone number, and needed form numbers.]
KY Notice of Election to Accept or Reject an Insurance Deductible *

Massachusetts
MA Construction Classification Premium Adjustment Program Application *
MA Notice of Election to Accept or Reject an Insurance Deductible *
MA Form 153: Affidavit of Exemption for Certain Corporate Officers or Directors *

Maryland
MD Form 19-1D: Construction Classification Premium Credit Application *
MD Form C-15R: Inclusion Form – Sole Proprietors/Partners *
MD Form IC-16: Exclusion Form *
MD Notice of Election to Accept or Reject an Insurance Deductible *

Maine
ME Notice of Election to Accept or Reject an Insurance Deductible *
ME Form WCB-2C: Application for Waiver *

Michigan
MI WC Specific Persons Exclusion Form *
MI Notice of Election to Accept or Reject an Insurance Deductible *

Missouri
MO Form 24-1 B: Contracting Classification Premium Adjustment Credit Application *
MO LLC Rejection of Coverage Form *

Minnesota
MN ERM-14: Confidential Request for Ownership Information *
MN Workers’ Comp Medical Loss Deductible Provisions *
MN Notice of Election to Accept or Reject an Insurance Deductible *

Mississippi
MS Drug-Free Workplace Program Certification Form *

Montana
MT Form NC-5000 D: Contracting Classification Premium Adjustment Credit App *
MT Notice of Election to Accept or Reject an Insurance Deductible *
MT Employment Verification Form *

North Carolina
NC ERM-14: Request for Ownership Information *
NC Certification of Drug-Free Workplace Program *
NC WC Drug-Free Workplace Premium Credit Program – Explanatory Memo *
NC Notice of Election to Accept or Reject an Insurance Deductible *

Nebraska
NE Form NC-5000 D: Contracting Classification Premium Adjustment Credit App *
NE Notice of Election to Accept or Reject an Insurance Deductible *

New Hampshire
NH Notice of Election to Accept or Reject an Insurance Deductible *

New Jersey
NJ Managed Care Program Agreement – AmGUARD *
NJ Managed Care Program Agreement – EastGUARD *
NJ Form PP-1B: Notice of Election – Proprietors/Partners WC and Employer’s Liability *

New Mexico
NM Form NC-5000 D: Contracting Classification Premium Adjustment Credit App *
NM Notice of Election to Accept or Reject an Insurance Deductible *
NM CID Sole Proprietor Affirmative Election Form *
NM Election to be Subject to Workers’ Compensation Act Form *
NM Executive Employee Affirmative Election Form *
NM Revocation of Prior Election Form *

Nevada
NV Notice of Election to Accept or Reject an Insurance Deductible *
NV Form D-45: Sole Proprietor Coverage *

New York
NY Employer – Preferred Provider Organization Affirmation (A) *
NY Employer and Union – Preferred Provider Organization Affirmation (B) *
NY Form 635V: Construction Classification Premium Adjustment Program Application *
NY Notice of Election to Accept or Reject an Insurance Deductible *
NY Form C-105.32: Election of WC Coverage – Sole Proprietor, Partner, LLC Members *
NY Form C-105.51: Exclusion from WC – Sole Shareholder, Ex. Officers, or Shareholders*
NY Form C-105.52: Not-for-Profit Organization to Exclude an Unsalaried Ex. Officer *
NY Form C-105.53: Revocation of the Election for Not-for-Profit Organizations *
NY Form C-105.55: Revocation of Exclusion of Sole Shareholder/Officers/Shareholders *
NY Drug-Free Workplace Rate Modification Program – Explanatory Memo *
NY Employer’s Certification of Drug & Alcohol Free Workplace Program *
NY Safe Patient Handling Act Compliance Checklist (Only certain class codes apply; contact Underwriting for details.) *
NY Workers’ Comp Drug-Free Workplace Memorandum *
NY Form SH 927: Workplace Safety & Loss Prevention Incentive Program Application *
NY Form SH 939: Workplace Safety & Loss Prevention Incentive Program Instructions *
NY Form SH 941: Workplace Safety & Loss Prevention Program Renewal Application *

Oklahoma
OK Form NC-5000D: Contracting Classification Premium Adjustment Credit App *
OK Form 35-3D: Workers’ Comp Deductible Acceptance/Rejection Form *

Oregon
OR Form NC-5000D: Contracting Classification Premium Adjustment Credit App *

Pennsylvania
PA PCRB Construction Classification Premium Credit Application *
PA Form LIBC 509: Application for Executive Officer Exception *
PA Form LIBC 513: Executive Officer’s Declaration *
PA Notice of Election to Accept or Reject an Insurance Deductible *

Rhode Island
RI Form DWC 11: Notice of Claim of Common Law Rights *
RI Form DWC 11R: Rescind Notice of Claim of Common Law Rights *
RI Form DWC 11C: Election by Exempt Corporate Officer to Become Subject to WC *
RI Notice of Election to Accept or Reject an Insurance Deductible *

South Carolina
SC Form 5: Corporate Officer Notice To Reject *
SC Form 39-1A: Application for Drug-Free and Alcohol-Free Workplace Credit *
SC Drug-Free and Alcohol-Free Workplace Credit – Miscellaneous Rules *
SC Notice of Election to Accept or Reject an Insurance Deductible *

Tennessee
TN Form LB-1111: Drug-Free Workplace Program Application *
TN Form I-4: Notice of Election of Sole Proprietor, Partner, or LLC Member *
TN Form I-5: Notice of Withdrawal of Form I-4 *
TN Form I-6: Corporate Officer Election To Employer Not to Accept Provisions of WC Act *
TN Form I-7: Notice of Corporate Officer’s Revocation of Exemption *
TN Form I-8: Notice of Acceptance of WC Act of TN by Exempted Employer *
TN Notice of Election to Accept or Reject an Insurance Deductible *

Texas
TX Form CS06-007A: Notice of Injured Employee Rights and Responsibilities *
TX Notice 5: Notice to Employees Concerning Workers’ Comp *
TX Notice 5r: For Use With Texas Notice 5 *
TX Notice 5s: Notice to Employees Concerning Workers’ Comp – Spanish *
TX Form DNE-1: Deductible Notice of Election *
TX Form DWC 81: Agreement between General Contractor and Subcontractor *
TX Form DWC 81S: Agreement between General Contractor and Subcontractor – Spanish *
TX Form DWC 82: Agreement for Motor Carriers and Owner Operators *
TX Form DWC 82S: Agreement for Motor Carriers and Owner Operators – Spanish *
TX Form DWC 83: Joint Agreement to affirm independent relationship for certain building and construction workers*
TX Form DWC 83s: Joint Agreement to affirm independent relationship for certain building and construction workers – Spanish*
TX Form DWC 84: Exception to application of joint agreement to affirm relationship for certain building and construction workers*
TX Form DWC 84S: Exception to application of joint agreement to affirm relationship for certain building and construction workers – Spanish*
TX Form DWC 85: Agreement between general contractor and subcontractor to establish independent relationship*
TX Form DWC 85S: Agreement between general contractor and subcontractor to establish independent relationship – Spanish*

Virginia
VA Drug-Free Workplace Drug Testing Program Application *
VA Notice of Election to Accept or Reject an Insurance Deductible *
VA Form 45-3E: Contracting Classification Premium Adjustment Credit Application *
VA Form 16A: Officer/Manager Rejection of Coverage *
VA Form 17A: Notice Terminating Prior Rejection of Coverage *

Vermont
VT Form 29: Application to Exclude Corporate Officers/LLC Members from WC*
VT Notice of Election to Accept or Reject an Insurance Deductible *

West Virginia
WV WC 99 03 02: Employers Liability Deliberate Intent Endorsement *
WV Form WVWC-RF01: Notice of Election/Rejection of Workers’ Compensation *

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