Commonly used forms for agents

Access forms used frequently by independent insurance agents.

SAM and ACH

• SFM Agency Manager (SAM) Registration Form
• SFM Authorization for Insurance Payments Via ACH

Supplemental questionnaires

• Supplemental Questionnaire​ — Allied Health
• Supplemental Questionnaire — Contractors
• Supplemental Questionnaire — Farms
• Supplemental Questionnaire — Health care: COVID-19
• Supplemental Questionnaire — Home Health
• Supplemental Questionnaire — Schools
• Supplemental Questionnaire — Trucking

Requests for ownership

• ERM-14 Form (Minnesota) – Confidential Request for Ownership Information
• ERM-14 Form (NCCI) – Confidential Request for Ownership Information
• ERM-14 Form (Wisconsin) – Confidential Request for Ownership Information

Indiana

• Indiana Workers’ Compensation Coverage Form
• Worker’s Compensation Board of Indiana state forms

Iowa

• Iowa Workers’ Compensation Election of Coverage
• Iowa Workers’ Compensation Rejection of Coverage

Kansas

• Kansas Cancellation of Election of Employer to Cover Employees Under Kansas Workers’ Compensation Act Where Employer Has Less than $20,000 Payroll or Is Agricultural Pursuit
• Kansas Cancellation of Election of Individual, Partner, Member of a Limited Liability Company or Self-Employed Individual to Come Within the Provisions of the Kansas Workers’ Compensation Act
• Kansas Cancellation of Election Not to Accept Coverage Under the Kansas Workers’ Compensation Act by Employee Who Owns 10% or More of Corporate Stock of Corporate Employer
• Kansas Election of Employer to Cover Employees Under Kansas Workers’ Compensation Act Where Employer has Less than $20,000 Payroll or is Agricultural Pursuit
• Kansas Election of Individual, Partner, Member of a Limited Liability Company or Self-Employed Individual to Come Within the Provisions of the Kansas Workers’ Compensation Act
• Kansas Election Not to Accept Coverage Under Kansas Workers’ Compensation Act by Employee Who Owns 10% or More of Corporate Stock of Corporate Employer

Minnesota

• Minnesota Workers’ Compensation Assigned Risk Plan Application
• Minnesota Workers’ Compensation Election of Coverage

Nebraska

• Nebraska Workers’ Compensation Election of Coverage
• Nebraska Workers’ Compensation Election of Coverage for Corporations
• Nebraska Workers’ Compensation Rejection of Coverage

South Dakota

• South Dakota Workers’ Compensation Election of Coverage
• South Dakota Workers’ Compensation Rejection of Coverage

Wisconsin

• Wisconsin Supplementary Election of Coverage
• Wisconsin Supplementary Non-Election of Coverage