Commonly used forms for agents
Access forms used frequently by independent insurance agents.
SAM and ACH
- Agent AutoPay consent form
- Authorization for insurance payments via ACH
- SFM Agency Manager (SAM) registration form
Supplemental questionnaires
- Supplemental questionnaire — Allied health
- Supplemental questionnaire — Contractors
- Supplemental questionnaire — Farms
- Supplemental questionnaire — Home health
- Supplemental questionnaire — Schools
- Supplemental questionnaire — Trucking
Requests for ownership
- ERM-14 Form (Minnesota) – Confidential request for ownership information
- ERM-14 Form (NCCI) – Confidential request for ownership information
- ERM-14 Form (Wisconsin) – Confidential request for ownership information
Indiana
Iowa
Kansas
- Kansas cancellation of election of employer to cover employees under Kansas Workers’ Compensation Act where employer has less than $20,000 payroll or is agricultural pursuit
- Kansas cancellation of election of individual, partner, member of a limited liability company or self-employed individual to come within the provisions of the Kansas Workers’ Compensation Act
- Kansas cancellation of election not to accept coverage under the Kansas Workers’ Compensation Act by employee who owns 10% or more of corporate stock of corporate employer
- Kansas election of employer to cover employees under Kansas Workers’ Compensation Act where employer has less than $20,000 payroll or is agricultural pursuit
- Kansas election of individual, partner, member of a limited liability company or self-employed individual to come within the provisions of the Kansas Workers’ Compensation Act
- Kansas election not to accept coverage under Kansas Workers’ Compensation Act by employee who owns 10% or more of corporate stock of corporate employer
Minnesota
- Minnesota Workers’ Compensation Assigned Risk Plan application
- Minnesota workers’ compensation election of coverage
Nebraska
- Nebraska workers’ compensation election of coverage
- Nebraska workers’ compensation election of coverage for corporations
- Nebraska workers’ compensation rejection of coverage
South Dakota
- South Dakota workers’ compensation election of coverage
- South Dakota workers’ compensation rejection of coverage
Tennessee
- Tennessee Form I-4 — Tennessee notice of election form
- Tennessee Form I-5 — Tennessee notice of withdrawal
- Tennessee Form I-6 — Notice of corporate officer to employer of election not to accept provisions of Workers’ Compensation Act
- Tennessee Form I-7 — Tennessee notice of corporate officer’s revocation of exemption
- Tennessee Form I-8 — Notice of acceptance of the Tennessee Workers’ Compensation Act by an exempted employer
- Tennessee Form I-9 — Tennessee notice of withdrawal of an exempt employers’ voluntary election
