Workers Compensation Certificate Of Insurance Form For Indiana

Please mail all required documentation to.

Workers compensation certificate of insurance form for indiana. Application for review by full board. Indiana first report of injury form. Form wce 1 must be filed along with 20 non refundable application fee in guaranteed funds. The state of indiana provides a free online tool for verifying workers compensation insurance coverage.

Disclosure is voluntary and you will not be penalized for refusal. Agreement to compensation between the dependents of deceased employee and employer. The results will only show the business name and policy number for employers who have coverage in the state being searched. Under our laws the state cannot tell employers they must automatically cover employees who contract covid 19.

If we already have a bond on the revised 2003 form or other approved security it is not necessary to include another with this application. Box 2305 indianapolis in 46206. Whether an individual contracts the virus in the course and scope of their employment is a determination that must initially be made by the employer. The standard acord 130 application form for workers comp coverage in indiana.

You must understand that the certificate is used by a broad spectrum of people for a variety of reasons. A current si 3 certificate of excess insurance must be on file with the board at all times. In indiana workers compensation benefits are paid by employers not the state. Whenever an employer or the employer s insurance carrier denies or is not able to determine liability to pay compensation or benefits the employer or the employer s insurance carrier shall notify the worker s compensation board and the employee in writing on a form prescribed by the worker s compensation board not later than thirty 30 days.

First report of injury form. The insurance certificate is written proof that workers compensation coverage is being provided for a certain group of workers. Anyone can search by business name or fein. The acord 125 form is the standard document used to issue certificates of insurance coverage.

Provider fee application for adjustment of claim. The acord form includes information about the insured including coverage type policy numbers expiration dates limits of coverage and key details. A valid surety bond or other approved security must be on file with the board at all times. Application for worker s compensation clearance certificate state form 45899 r7 3 15 approved by state board of accounts 2015 worker s compensation board of indiana this agency is requesting disclosure of your social security number in accordance with ic 4 1 8 1.

Employers should complete this form and send to their insurance company each time an injury occurs. Indiana workers compensation verification. First report of injury 34401. Application for adjustment of claim.

For more information regarding a worker s compensation exemption certificate tax clearance you may contact dor s compliance check unit at 317 232 5977. Indiana department of revenue p o.