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Board Forms

PDF files for several of the Workers Compensation Board of Indiana forms.;

We are often asked to send copies of Board forms to agents, especially when they are completing assigned risk applications. Attached are forms in Acrobat file format (PDF) that anybody with internet access should be able to open and print. The documents contain interactive form fields. Adobe Acrobat Reader is free software and available for download at www.adobe.com.
 
You can attach these files below to an email and send them to anyone. The Board supplies forms free of charge and can be reached at 317.232.3808. Although the Board accepts photocopies of forms, it requires original signatures.

(1) "Election Form"
Notice For Workers Compensation and Occupational Diseases Coverage
State Form 36097 (R4 / 3-09)
Notes:
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, updated in March 2009, now has a check box for LLC Members.
3. The bottom section of the form replaces State Form 46 and now includes elections for:
  • farm or agricultural employees
  • household employees
  • part-time volunteer coaches for non-profit corporation
  • casual laborers 
 
(2) "Clearance Certificate"
WCE-1 Workers Compensation Clearance Certificate Application
State Form 45899 (R6 / 12/09)
Previous version:
State Form 45899 (R3 / 7/06)

(3) "First Report of Injury "
First Report of Employee Injury, Illness
State Form 34401 (R9 / 3-01)


 
Worker's Compensation Board of Indiana
402 West Washington Street Room W-196
Indianapolis, Indiana 46204
 

Related Files
Employee vs. Independent Contractor

Author CN=Ron Cooper/O=ICRB
Last Modified By Ron Cooper
Last Modified Date 02/06/2010 11:14 AM

The material in this document has been prepared and shared for informational purposes only and should not be relied upon as legal advice on any particular situation.