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State Forms & Regulatory Links

Alabama +

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AL Fraud Poster

AL Application for Certification of Drug-Free Workplace Premium Credit

AL Application for Re-Certification of Drug-Free Workplace Premium Credit

AL Notice of Election to Accept or Reject an Insurance Deductible

AL - Notice to Exclude or Include Coverage for Himself, Officers or Members

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Dept of Industrial Relations and Workers Comp

Florida +

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FL Anti-Fraud Notice

FL Notice of Election of Coverage

FL Revocation of Election of Coverage

FL Application for Drug-Free Workplace Premium Credit

FL Certification of Employer Workplace Safety Program Premium Credit

FL Deductible Plan Election

FL Battle Against Workers' Comp Fraud

FL Battle Against Workers' Comp Fraud - Spanish

Links

Bureau of Workers’ Compensation Fraud

Georgia +

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State Board of Workers' Compensation Notice of Election or Rejection of Coverage - GA

GA Application for Certification or Annual Recertification of Drug-Free Workplace Premium Credit

GA Notice of Election to Accept or Reject an Insurance Deductible

Links

State Board of Workers’ Compensation

Indiana+

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Notice for Workers' Compensation & Occupational Diseases Coverage - IN

IN Notice of Election to Accept or Reject an Insurance Deductible

Links

Workers’ Compensation Board of Indiana

Kentucky+

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First Report of Injury [Form IA-1]

Employee's Notice of Rejection of Workers' Compensation Act - KY

KY Application for Certification of Drug-Free Workplace Program

KY Notice of Election to Accept or Reject an Insurance Deductible

Links

Workers’ Compensation of Kentucky

Mississippi +

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Wage Statement

MS Notice of Election or Rejection of Workers' Compensation

MS Application for Certification of Drug-Free Workplace Program

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Workers’ Compensation Commission

North Carolina +

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NC Exemption Form

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Industrial Commission
NCRB ERM-14 – Electronic Submission Only

South Carolina +

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SC Corporate Officer Notice to Reject

SC Application for Drug-and Alcohol-Free Workplace Premium Credit

SC Notice of Election to Accept or Reject an Insurance Deductible

Links

Workers’ Compensation Commission

Tennessee +

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TN Workers' Compensation Insurance Posting Notice

TN Election of Sole Proprietor or Partner to Come within the Provisions of Workers' Compensation Law [Form I-4]

TN Notice of Corporate Officer to Employer of Election Not to Accept Provisions of Workers' Compensation Act [Form I-6]

TN Application for Drug-Free Workplace Premium Credit

TN Notice of Election to Accept or Reject an Insurance Deductible

TN Workers' Compensation Insurance Posting Notice - Spanish

TN Notice of Corporate Officer's Revocation of Exemption [Form I-7]

TN Notice of Withdrawal [Form I-5]

Links

Bureau of Workers’ Compensation

Virginia +

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VA Notice of Election of Coverage

VA Revocation of Prior Rejection of Coverage Form 17A

VA Application for Drug-Free Workplace Premium Credit

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Virginia Workers’ Compensation Commission
Option to file Rejection of Coverage Waiver Form 16A