Agent forms and links
Workers’ comp forms and state-specific web links
Forms
- ERM-14 confidential request for ownership information – NCCI
- SFM agent AutoPay consent form
- SFM Agency Manager (SAM) registration form
Supplemental questionnaires
- Allied health care supplemental questionnaire
- Contractor supplemental questionnaire
- Farm supplemental questionnaire
- Home health supplemental questionnaire
- School supplemental questionnaire
- Trucking owner operator supplemental questionnaire
- Trucking supplemental questionnaire
Links
Forms
Links
Forms
- 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
- 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
- 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
- Election of employer to cover employees under Kansas Workers’ Compensation Act where employer has less than $20,000 payroll or is agricultural pursuit
- 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
- Election not to accept coverage under Kansas Workers’ Compensation Act by employee who owns 10% or more of corporate stock of corporate employer
Links
Forms
- Election of coverage – Minnesota
- ERM-14 confidential request for ownership information – Minnesota
- Minnesota Workers’ Compensation Assigned Risk Plan (MWCARP) application
- Zero payroll policy attestation form – Minnesota
Links
- Insurance Federation of Minnesota
- Minnesota Chamber of Commerce
- Minnesota Department of Commerce
- Minnesota Department of Labor and Industry
- Minnesota Independent Insurance Agents and Brokers of America (IIABA)
- Minnesota Union Construction Work Comp Program (UCWCP)
- Minnesota Workers’ Compensation Insurers Association (MWCIA)
- Minnesota workers’ compensation statutes
- Professional Insurance Agents of Minnesota (PIA)
- Verification of insurance coverage
Forms
- I-4 – Tennessee notice of election form
- I-5 – Tennessee notice of withdrawal
- I-6 – Notice of corporate officer to employer of election not to accept provisions of Workers’ Compensation Act
- I-7 – Tennessee notice of corporate officer’s revocation of exemption
- I-8 – Notice of acceptance of the Tennessee Workers’ Compensation Act by an exempted employer
- I-9 – Tennessee notice of withdrawal of an exempt employers’ voluntary election
Forms
