Workers Compensation ACORD Forms


ACORD 4 – Workers Compensation – First Report of Injury or Illness
ACORD 64US – Insurance Supplement – Workers’ Compensation Only
ACORD 125 – Commercial Insurance Application – Applicant Information Section
ACORD 130 – Workers Compensation Application
ACORD 133 – Workers Compensation Insurance Plan Assigned Risk Section


Alaska Workers Compensation ACORD Forms

ACORD 171AK – Alaska Petition for Executive Officer Waiver


Colorado Workers Compensation ACORD Forms

ACORD 171CO – Colorado Rejection of Coverages by Corporate Officers


Connecticut Workers Compensation ACORD Forms

ACORD 171CT – Workers’ Compensation Commission of Connecticut
ACORD 172CT – Workers’ Compensation Commission of Connecticut
ACORD 173CT – Workers’ Compensation Commission of Connecticut


Delaware Workers Compensation ACORD Forms

ACORD 171DE – Delaware Workers Compensation


Florida Workers Compensation ACORD Forms

ACORD 130FL – Florida Workers Compensation Application
ACORD 133FL – Florida Workers Compensation Application
ACORD 134FL – Florida Workers Compensation Joint Underwriting Association Inc.
ACORD 171FL – Florida Notice of Election of Coverage Under Workers Compensation Law
ACORD 172FL – Florida Revocation of Election to be Exempt
ACORD 173FL – Notice of Election to be Exempt
ACORD 175FL – Florida Workers Compensation Monthly Change Sheet


Georgia Workers Compensation ACORD Forms

ACORD 171GA – Georgia State Board of Workers Compensation Notice of Election or Rejection of Workers’ Compensation Coverage


Kansas Workers Compensation ACORD Forms

ACORD 171KS – Kansas Election of Individual Partner or Self-Employed Individual
ACORD 172KS – Kansas Cancellation of Election of Individual
ACORD 173KS – Kansas Cancellation of Election Not to Accept Coverage
ACORD 174KS – Kansas Election Not to Accept Coverage
ACORD 176KS – Kansas Election of Employer to Cover Employees
ACORD 177KS – Kansas Election of Coverage for Volunteer Workers
ACORD 178KS – Kansas Cancellation of Election of Employer To Cover Employees
ACORD 179KS – Kansas Cancellation of Election of Coverage for Volunteer Workers
ACORD 180KS – Kansas Election of Coverage for Persons Performing Public Service
ACORD 181KS – Kansas Cancellation of Election of Coverage for Persons Performing Public Service
ACORD 182KS – Kansas Election of a Noncompensated Volunteer To Be Covered
ACORD 183KS – Kansas Cancellation of Election of a Noncompensated Volunteer To Be Covered


Michigan Workers Compensation ACORD Forms

ACORD 133MI – Michigan Application for Workers’ Compensation Insurance
ACORD 171MI – Michigan Notice of Election
ACORD 172 – Michigan Application for Exclusion of Partner(s)
ACORD 173MI – Michigan Workers Compensation Placement Facility Specific Person Exclusion Form


New Jersey Workers Compensation ACORD Forms

ACORD 132NJ – New Jersey Workers Compensation Insurance Plan Instructions and Rules
ACORD 133NJ – New Jersey Workers Compensation Insurance Plan Application
ACORD 134NJ – New Jersey Workers Compensation Insurance Plan Notice of Election – Proprietors and Partners
ACORD 135NJ – New Jersey Workers Compensation Insurance Plan – Supplemental Employee Leasing Application
ACORD 136NJ – New Jersey Workers Compensation Insurance Plan – Truckers Supplemental Application
ACORD 171NJ – New Jersey Workers Compensation Insurance Plan – New Jersey Workers Compensation and Employers Liability Manual, Part 3, Sectino 14


New Mexico Workers Compensation ACORD Forms

ACORD 171NM – New Mexico Executive Employee Exemption
ACORD 172NM – New Mexico Election to Accept
ACORD 173NM – New Mexico Revocation


New York Workers Compensation ACORD Forms

ACORD 171NY – New York Notice of Election of a Corporation
ACORD 172NY – New York Notice of Election of a Partnership or Sole Proprietorship to Bring Partners or Self-Employed Persons Under the Coverage of the New York Workers Compensation Law
ACORD 173NY – New York Notice of Election of an Incorporated Religious
ACORD 174NY – New York Revocation of an Incorporated Religious


North Carolina Workers Compensation ACORD Forms

ACORD 133NC – North Carolina workers Compensation Insurance Plan
ACORD 134NC – North Carolina Workers Compensation Insurance Plan


Pennsylvannia Workers Compensation ACORD Forms

ACORD 171PA – Pennsylvania Application for Executive Officer Exception From the Provisions of the Pennsylvania Workers’ Compensation Act: Section 104
ACORD 172PA – Pennsylvania Executive Officers Declaration


Tennessee Workers Compensation ACORD Forms

ACORD 133TN – Tennessee Workers Compensation Insurance Plan Assigned Risk Supplement
ACORD 171TN – Notice of Corporate Officer to Employer of Election Not to ACcept Provisions of
ACORD 172TN – Notice of Corporate Officer’s Revocation of Exemption
ACORD 173TN – Election of Sole Proprietor or Partner to Come Within the Provisions of the Tennessee Workers’ Compensation Law
ACORD 174TN – Notice of Withdrawal of Sole Proprietor or Partner Election


Virginia Workers Compensation ACORD Forms

ACORD 171VA – Virginia Rejection of Coverage Under the Virginia Workers’ Compensation Act
ACORD 172VA – Virginia Notice Terminating Prior Rejection of Coverage


Wisconsin Workers Compensation ACORD Forms

ACORD 4WI – Wisconsin Employer’s First Report of Injury or Disease