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State Forms & Regulatory Links

Alabama +

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 Notice of Election to Accept or Reject an Insurance Deductible

Links

Dept of Industrial Relations and Workers Comp
Dept of Insurance
State Portal

Florida +

FL Application for Drug-Free Workplace Premium Credit

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

Notice of Election to be Exempt
Notice of Revocation of Election to be Exempt
Division of Insurance Fraud
Dept of Financial Services
Dept of State
State Portal
Government

Georgia +

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

Insurance and Safety Fire Commissioner
Dept of Insurance
State Board of Workers’ Comp
Secretary of State
Government
Producer Appointment Form

Indiana+

IN Notice of Election to Accept or Reject an Insurance Deductible

Notice for Workers' Compensation & Occupational Diseases Coverage - IN

Links

Indiana Dept of Insurance
Indiana Secretary of State
WC Board of Indiana

Kentucky+

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

Coming soon.

Mississippi +

MS Application for Certification of Drug-Free Workplace Program

MS Notice of Exemption

No Treatment Requested Letter

Notice of Election or Rejection of Workers' Compensation - MS

Wage Statement

Links

Workers’ Comp Commission
Dept of Insurance
Secretary of State

North Carolina +

NC Exemption Form

NCRB ERM-14 Form

Links

Dept of Insurance
Rate Bureau
Dept of the Secretary of State
Industrial Commission

South Carolina +

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’ Comp Commission
Secretary of State
Other Forms
Dept of Insurance

Tennessee +

Election of Sole Proprietor or Partner to Come within the Provisions of Workers' Compensation Law - TN

Notice of Corporate Officer to Employer of Election Not to Accept Provisions of Workers' Compensation Act - TN

Notice of Corporate Officer's Revocation of Exemption - TN

Notice of Withdrawal - TN

TN Application for Drug-Free Workplace Premium Credit

TN Notice of Election to Accept or Reject an Insurance Deductible

Links

Dept of State
Dept of Labor & Workforce Development
Dept of Commerce and Insurance

Virginia +

VA Notice of Election of Coverage

VA Rejection of Coverage Form 16A

VA Revocation of Prior Rejection of Coverage Form 17A

Links

Bureau of Insurance
Secretary of the Commonwealth
State Portal
WC Commission