Forms for licensed insurers

The following forms are for licensed insurers to use.

Licensed Insurer Forms

 PDF Licensed insurer form - Application  (Pub No LI-680, 01/01/2011, 1.0 136.5 KB)

This is the application form for licensed insurers.

 PDF Licensed insurer form - Injury management program application  (Pub No LI-645, 01/01/2011, 1.0 141.5 KB)

This is an application form for injury management programs.

 PDF Licensed insurer form - Irrevocable power of attorney deed and schedule  (Pub No LI-685, 01/01/2011, 1.0 90.5 KB)

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

 PDF Licensed insurer form - Injury Management Program Renewal Application Form.doc  (Pub No LI-645A, 01/01/2003, 1 141.5 KB)

This form is used to apply for renewal of a previously approved Injury Management Program

 PDF G-3 End of Year Reconciliation Certificate  (Pub No G-3, 01/01/2003, G-3 260.4 KB)

This form is to be used for the end of year reconciliation certificate.

 PDF G-5 Insurer form - Independent audit report template  (Pub No LI-675, 01/01/2011, 1.0 150.5 KB)

This document helps insurers submit the required independent audit report.

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