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State Forms & Regulatory Links

Alabama +

Alabama

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

AL Application for Certification of Drug-Free Workplace Premium Credit

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

AL Fraud Poster

AL Notice of Election to Accept or Reject an Insurance Deductible

Links

Dept of Industrial Relations and Workers Comp

Florida +

Florida

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FL Anti-Fraud Notice

FL Application for Drug-Free Workplace Premium Credit

FL Application for Drug-Free Workplace Premium Credit

FL Battle Against Workers' Comp Fraud

FL Battle Against Workers' Comp Fraud - Spanish

FL Certification of Employer Workplace Safety Program Premium Credit

FL Deductible Plan Election

FL Notice of Election of Coverage

FL Revocation of Election of Coverage

Links

Bureau of Workers’ Compensation Fraud

Georgia +

Georgia

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

GA Notice of Election to Accept or Reject an Insurance Deductible

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

Links

State Board of Workers’ Compensation

Indiana+

Indiana

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IN Notice of Election to Accept or Reject an Insurance Deductible

Notice for Workers' Compensation & Occupational Diseases Coverage - IN

Links

Workers’ Compensation Board of Indiana

Kentucky+

Kentucky

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

First Report of Injury [Form IA-1]

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 +

MIssissippi

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MS Application for Certification of Drug-Free Workplace Program

MS Notice of Election or Rejection of Workers' Compensation

MS Notice of Exemption

Wage Statement

Links

Workers’ Compensation Commission

North Carolina +

North Carolina

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NC Exemption Form

NCRB ERM-14 Form

Links

Industrial Commission

South Carolina +

South Carolina

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

SC Corporate Officer Notice to Reject

SC Notice of Election to Accept or Reject an Insurance Deductible

Links

Workers’ Compensation Commission

Tennessee +

Tennessee

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TN Application for Drug-Free Workplace Premium Credit

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

TN Notice of Election to Accept or Reject an Insurance Deductible

TN Notice of Withdrawal [Form I-5]

TN Workers' Compensation Insurance Posting Notice - Spanish

Links

Bureau of Workers’ Compensation

Virginia +

Virginia

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VA Notice of Election of Coverage

VA Rejection of Coverage Form 16A

VA Revocation of Prior Rejection of Coverage Form 17A

Links

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