Forms
Click 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.
After previewing or printing, close the form window
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 | |
| Acord 130 Instructions | Workers Compensation Application Information | |
| Acord 133 | Workers Compensation Insurance Plan | |
| Acord 133 Instructions | Workers Compensation Insurance Plan Information | |
| PEO Client App | Supplemental Employee Leasing Application | |
| PEO App | Supplemental Employee Leasing Application | |
| Temp. Agency Info | Temporary Employment Contractor Information | |
| WC Board | ||
| State Form 36097 | Notice for Workers Compensation and Occupational Diseases Coverage | |
| State Form 45899 | Worker’s Compensation Clearance Certificate Application | |
| Others | ||
| ERM-6 | Workers Compensation Experience Rating for Non-Affiliate Data | |
| ERM-14 | Confidential Request for Ownership Information | |
| Inspection Request | Inspection Request | Web page |