Other 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

Click here to complete & submit the form online.
Alabama: Employer's First Report of Injury
Arkansas: First Report of Injury or Illness
Florida: First Report of Injury or Illness
Georgia: First Report of Injury or Occupational Disease
Louisiana: First Report of Injury or Illness
Mississippi: First Report of Injury or Illness
Missouri: Report of Injury
New Jersey: First Report of Injury or Illness
North Carolina: Employer's Report of Employee's Injury or Occupational Disease to the Industrial Commission
Oklahoma: First Notice of Claim For Compensation
Pennsylvania: First Report of Injury
Texas: First Report of Injury or Illness
Virginia: First Report of Injury

Alabama Specific Forms

Employer's First Report of Injury
Alabama State Specific Forms
Drugfree Workplace

Arkansas Specific Forms

First Report of Injury or Illness
Arkansas State Specific Forms
HS-36-A Drugfree Workplace

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

Louisiana Specific Forms

First Report of Injury or Illness
Louisiana State Specific Forms

Mississippi Specific Forms

First Report of Injury or Illness
Mississippi State Specific Forms

North Carolina Specific Forms

Employer's Report of Employee's Injury or Occupational Disease to the Industrial Commission
North Carolina State Specific Forms

Oklahoma Specific Forms

First Notice of Claim For Compensation
Oklahoma State Specific Forms

Pennsylvania Specific Forms

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

Texas Specific Forms

First Report of Injury or Illness
Texas State Specific Forms

Virginia Specific Forms

First Report of Injury
16A Rejection of Coverage
Address Change

Resources

Arkansas Agents

AR Workers’ Comp Commission - www.awcc.state.ar.us
Independent Agents of AR - www.iiaar.org

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 - dwcdataportal.fldfs.com
This link has a number of useful state databases, such as Proof of Coverage and WC Policy Search

Georgia Agents

Independent Insurance Agents of GA - www.iiag.org
State Board of Workers' Compensation - sbwc.georgia.gov

Louisiana Agents

LA Workers’ Comp Commission - www.laworks.net
Independent Agent of LA - www.iiabl.com

Mississippi Agents

MS Workers’ Comp Commission - mwcc.ms.gov
Independent Agent of MS - www.msagent.org

North Carolina Agents

NC Industrial Commission - www.ic.nc.gov
NC Rating Bureau - www.ncrb.org
NC Coverage Database - ccms.ic.nc.gov
Independent Agent of NC - www.iianc.com

Oklahoma Agents

OK Workers’ Comp Commission - www.ok.gov
Independent Agent of OK - www.iiaok.com

Pennsylvania Agents

Experience Modifications - www.dcrb.com
Coverage verification and Bureau code search - www.dli.pa.gov
Independent Agents of PA, MD, and DE - www.iabforme.com

Texas Specific Forms

TX Dept of Insurance - www.tdi.texas.gov
Agent appointments - www.tdi.texas.gov
Coverage verification through TX Comp - www.tdi.texas.gov
Independent Agents of TX - www.iiat.org

Virginia Agents

Professional Insurance Agents Association - Virginia and DC - www.piavadc.com
VA Workers' Compensation Commission - vwc.state.va.us


keyboard_arrow_up
TOP