WC Board Forms

Forms for Workers Compensation Board of Indiana.

The ICRB is often asked to provide copies of the Workers Compensation Board forms to agents, especially when they are completing Assigned Risk applications. Below you will find these fillable forms in Acrobat file format (PDF). Adobe Acrobat Reader is free software and available for download at www.adobe.com. The WC Board supplies forms free of charge and can be reached at 317.232.3808. Although the WC Board accepts photocopies of forms, it requires original signatures.

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 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.

All forms should be submitted to:
Worker’s Compensation Board of Indiana
402 West Washington Street Room W-196
Indianapolis, Indiana 46204