Forms and Resources

Forms and Links

All States

ERM-14 and Instructions
Broker/Agent of Record Sample
NCCI Mod Authorization Form
Online Officer Exemption

First Report Of Injury Forms

Florida First Report Of Injury or Illness
Georgia First Report Of Injury or Occupational Disease
Pennsylvania First Report Of Injury
Virginia First Report Of Injury

Florida Specific Forms

DFS-F2-DWC-1 First Report Of Injury or Illness
09-1 Drug Free Application
09-3 Safety Credit Form
09-4 FCCPAP Form (Florida Contracting Classification Premium Adjustment Program)

Georgia Specific Forms

W-1 First Report Of Injury or Occupational Disease
Drug Free Credit – Online only
WC-10 Election or Rejection of Coverage
Drug Free Application

Pennsylvania Specific Forms

LIBC-90 First Report Of Injury
LIBC-500 Remember: It is Important to tell Your Employer About your Injury

Virginia Specific Forms

3 Virginia First Report Of Injury
16A Rejection of Coverage
Drug Free Credit
Address Change

Resources

Florida Agents

Florida Association of Insurance Agents (FAIA)
www.faia.com

Latin American Association of Insurance Agencies
www.laaia.com

Home Page for the Florida Division of Workers' Compensation Website
www.myfloridacfo.com

Division of Workers' Compensation Databases
This link has a number of useful state databases, such as Proof of Coverage and WC Policy Search
www.myfloridacfo.com


Georgia Agents

Independent Insurance Agents of Georgia
www.iiag.org

State Board of Workers' Compensation
sbwc.georgia.gov


Pennsylvania Agents

Coming Soon!


Virginia Agents

Professional Insurance Agents Association - Virginia and DC
www.piavadc.com

Virginia Workers' Compensation Commission
vwc.state.va.us


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