Applications & Supplements

Workers’ Compensation

Workers’ Compensation Application

Workers’ Compensation Supplemental Application

Workers’ Compensation Contractor’s Supplemental Questionnaire

Workers’ Compensation Garage Supplement

Workers’ Compensation Officer Exclusion Forms

Delaware

This form must be on file with the insurance company:

Delaware Officer Exclusion form

Maryland

This form must be filed with the Maryland Workers’ Compensation Commission and a copy must be on file with the insurance company:

Maryland Officer Exclusion form

North Carolina

This form must be on file with the insurance company:

North Carolina

Pennsylvania

These forms must be on file with the insurance company:

Pennsylvania Application for Executive Officer Exception form

Pennsylvania Executive Officers Declaration form

Virginia

This form must be filed with the Virginia Workers’ Compensation Commission and a copy must be on file with the insurance company:

Virginia Officer Exclusion form

Other Applications and Supplements

Coal Mine Liability – Pollution Liability Application

ERM-14-(NCCI)

ERM-14-(PA, DE)

Excavation Contractor Supplemental Questionnaire

Fuel Oil Dealers Supplement

General Liability Contractor Supplemental Questionnaire

Logging Supplement

Marina Supplemental Application

Residential Health Care Questionnaire

Special Events Application

Sporting Goods Store & Shooting Range Supplemental Application

Truckers Workers Compensation Supplemental