We are often asked to send copies of Board forms to agents, especially when they are completing assigned risk applications. Attached are forms in Acrobat file format (PDF) that anybody with internet access should be able to open and print. The documents contain interactive form fields. Adobe Acrobat Reader is free software and available for download at www.adobe.com.
You can attach these files below to an email and send them to anyone. The Board supplies forms free of charge and can be reached at 317.232.3808. Although the Board accepts photocopies of forms, it requires original signatures.
(1) "Election Form"
Notice For Workers Compensation and Occupational Diseases Coverage
1. To rescind an election, the Board does not have a form, so a letter to the Board and carrier should be acceptable.
2. The form, updated in March 2009, added a check box for LLC Members.
3. The bottom section of the form replaces State Form 46 and includes elections for:
4. The form, updated in June 2014, now has a check box for corporate officer exclusion election.
5. The form, updated in June 2015, now specifies an officer must have “...an ownership interest in the above named corporation...” to qualify for exclusion.
6. The form may be signed by "the employer or authorized agent". Per the WC Board, anyone authorized to sign documentation on behalf of the employer is an authorized agent. As such, the insurance agent could be considered an authorized agent. This is primarily due to the fact that the agent is in the best position to have knowledge of the information needed to submit the form, and also because the Act requires that the carrier and Board be noticed on these filings.
(2) "Clearance Certificate"
WCE-1 Workers Compensation Clearance Certificate Application
(3) "First Report of Injury"
First Report of Employee Injury, Illness