Forms for licensed insurersThe following forms are for licensed insurers to use.
Licensed Insurer Forms
Licensed insurer form - Application (Pub No LI-680, 01/01/2011, 1.0 136.5 KB)
This is the application form for licensed insurers.
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.
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.
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
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.
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.