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Forms

Wheelbarrow of FormsClick on the Forms links to the left or below to open.

The opened form can be printed out, and then can be mailed or faxed to ICRB at the address or fax number listed below. The Inspsection Request can be submitted online.

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to return to the ICRB web site.

Please be sure to call or e-mail us with any questions or problems.

Form Name
Click on Name to Open
Description File Type
Assigned Risk
Acord 130 Workers Compensation Application PDF
Acord 130 Instructions Workers Compensation Application Information PDF
Acord 133 Workers Compensation Insurance Plan PDF
Acord 133 Instructions Workers Compensation Insurance Plan Information PDF
PEO Client App Supplemental Employee Leasing Application PDF
PEO App Supplemental Employee Leasing Application PDF
Temp. Agency Info Temporary Employment Contractor Information PDF
WC Board
State Form 36097 Notice for Workers Compensation and Occupational Diseases Coverage PDF
State Form 45899 Worker’s Compensation Clearance Certificate Application PDF
Others
ERM-6 Workers Compensation Experience Rating for Non-Affiliate Data PDF
ERM-14 Confidential Request for Ownership Information PDF
Inspection Request Inspection Request Web page