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Policy application forms

Of course forms are involved—it's an insurance transaction after all. If your agent or a SAIF representative asks you to submit one during the application process (in addition to the standard ACORD form), you'll find everything you need right here.

Form nameReference number
ACORD™ workers' compensation application form
Use this form to apply for SAIF coverage. Please contact us for assistance.
ACORD
Cancellation of election for coverage as a worker
To cancel personal election coverage for an owner, this form is to be completed by an authorized representative of the business.
X-3000
Personal coverage application for nonsubject corporate officers
To elect coverage for a nonsubject corporate officer, this form is to be completed by an authorized corporate representative.
X-1460
Personal coverage application for sole proprietors, nonsubject partners, or nonsubject limited liability company (LLC) members
To elect coverage for a sole proprietor, nonsubject partner, or nonsubject LLC member, this form is to be completed by the owner, a partner, or an LLC member in the business.
X-1461b
Designation of Corporate Officer Exemption form | Construction, Timber Harvest, or Landscape Industries
To exempt a corporate officer from coverage, this form is to be completed by an authorized corporate representative.

X-3267

Designation of Partner or LLC Member Exemption form | Construction or Landscape Industries
To exempt a partner or LLC member from coverage, this form is to be completed by a partner or LLC member.
X-3327b
ERM-14 form | Confidential request for ownership information
Use this NCCI form to notify SAIF of ownership and/or entity changes in your business.
ERM-14
Nondisabling Claims Reimbursement form
This form is available to each new and renewing policyholder on an annual basis as an offer to participate in the claims reimbursement program. If you choose to participate, return a signed form to SAIF.
F-3135
Policyholder's Cancellation of Workers' Compensation Insurance
To cancel your workers' compensation insurance policy, this form is to be completed by an authorized representative of the business.
X-773
Premium credit application
This application is for policyholders or agents to complete.
X-948