Forms

Forms for licensed insurers

The following forms are for licensed insurers to use.

Licensed Insurer Forms

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Licensed insurer form - Pro-Forma for Insurer Indusrty Premium Rate FilingsWord Icon

This is a proforma for insurer industry premium rate filings and definitions of terms.

  • Date: 01/01/2011
  • |Pub No: LI-670
  • |Size: 296.5 KB, 3 Pages
  • |Version: 1.0
  • |Format: WORD
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Licensed insurer form - ApplicationWord Icon

This is the application form for licensed insurers.

  • Date: 01/01/2011
  • |Pub No: LI-680
  • |Size: 134.0 KB, 1 Pages
  • |Version: 1.0
  • |Format: WORD
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Licensed insurer form - Injury management program applicationWord Icon

This is an application form for injury management programs.

  • Date: 01/01/2011
  • |Pub No: LI-645
  • |Size: 141.5 KB, 2 Pages
  • |Version: 1.0
  • |Format: WORD
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Licensed insurer form - Irrevocable power of attorney deed and scheduleWord Icon

This is the Irrevocable Power of Attorney Deed and Schedule form for licensed insurers.

  • Date: 01/01/2011
  • |Pub No: LI-685
  • |Size: 90.5 KB, 9 Pages
  • |Version: 1.0
  • |Format: WORD
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Licensed insurer form - Industrial deafness compensationWord Icon

This is the form for determining payment for industrial deafness compensation form ,for licensed insurers.

  • Date: 01/01/2011
  • |Pub No: LI-687
  • |Size: 136.5 KB, 1 Pages
  • |Version: 1.0
  • |Format: WORD