Commonly used forms for agents
Access forms used frequently by independent insurance agents.
SAM and 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
Iowa
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
Tennessee
- Tennessee Form I-4 — Tennessee notice of election form
- Tennessee Form I-5 — Tennessee notice of withdrawal
- Tennessee Form I-6 — Notice of corporate officer to employer of election not to accept provisions of Workers’ Compensation Act
- Tennessee Form I-7 — Tennessee notice of corporate officer’s revocation of exemption
- Tennessee Form I-8 — Notice of acceptance of the Tennessee Workers’ Compensation Act by an exempted employer
- Tennessee Form I-9 — Tennessee notice of withdrawal of an exempt employers’ voluntary election
