Applications & Supplements

View our workers' compensation and supplemental application forms

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

Artisan’s Contractor Program Application

Beautician’s Application

Coal Mine Liability – Pollution Liability Application

Coal Trucker’s Commercial Auto Application

ERM-14-(NCCI)

ERM-14-(PA, DE)

Excavation Contractor Supplemental Questionnaire

Fuel Oil Dealers Supplement

General Liability and Artisan Contractor Supplemental Questionnaire

Logging Supplement

Marina Supplemental Application

Residential Health Care Questionnaire

Special Events Application

Office Locations

654 Main St.
Rockwood, PA 15557

Toll-Free Phone: 800-837-9062
Phone: 814-926-4661
Fax: 814-926-3249

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