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The opened form can be printed out, and then can be mailed or faxed to ICRB at the address or fax number listed below. The Inspsection Request can be submitted online.

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Please be sure to call or e-mail us with any questions or problems. Note: For ACORD forms 130 and 133, for copyright restrictions, please go to ACORD website at www.acord.org.

Form Name
Click on Name to Open
Description File Type
Assigned Risk
PEO Client App Supplemental Employee Leasing Application PDF
PEO App Supplemental Employee Leasing Application PDF
Temp. Agency Info Temporary Employment Contractor Information PDF
WC Board
State Form 36097 Notice for Workers Compensation and Occupational Diseases Coverage PDF
Clearance #45899 Worker’s Compensation Clearance Certificate Application PDF
Others
ERM-6 Workers Compensation Experience Rating for Non-Affiliate Data PDF
ERM-14 Confidential Request for Ownership Information PDF
Inspection Request Inspection Request Web page