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Risk Services & PBOA Underwriting Forms

Florida ACORD 130 FL (2002/07)
Florida Workers’ Compensation application

ACORD 130 (2005/08)
General Workers’ Compensation application

Application for Employer
Workplace Safety Program Credit
Policyholders in Florida can qualify for a credit if they have a safety program in place. They must complete this form and have it notarized to apply for the credit.

Application for Drug-Free Workplace
Premium Credit Program
Policyholders in Florida can qualify for a credit if they have a drug-free workplace program in place. They must complete this form and have it notarized to apply for the credit.

Florida Contracting Classification Premium
Adjustment Program Application (FCCPAP)
This program provides for a premium credit for up to one year for a policy that contains one or more contracting classification codes. Forms are to be submitted directly to NCCI.

ERM-14
Instructions on how to complete an ERM-14

Contractors Questionnaire
Supplemental Underwriting questionnaire needed for contracting risks.