Skip to content
  • Kentucky's leading provider of workers' comp insurance
  • About KEMI
  • Safety & Training
  • En Español
  • Careers
  • Contact
  • Kentucky's leading workers' comp provider
KEMIKEMI
  • Home
  • Employers
    • Employer Resources
      • How Workers’ Comp Works
      • Why Choose KEMI?
      • Find an Agent
      • Safety & Training
      • Claims Management
      • The Audit Process
      • Employer Forms
      • Frequently Asked Questions
    • Manage My Policy
      • View Policy Details
      • Manage Alerts
      • Make a Payment
      • Obtain Certificate of Insurance
      • Order Coverage Posters
      • Complete an Audit
      • Generate Loss Run
      • View Billing History
    • Manage My Claims
      • Report an Incident
      • Claim Detail Dashboard
      • Find a Medical Provider
      • Report Fraud
  • Agents
    • Agent Resources
      • How Workers’ Comp Works
      • Why Choose KEMI?
      • Rates
      • Commissions
      • Other States Coverage
      • Safety & Training
      • Claims Management
      • The Audit Process
      • Agent Forms
      • Frequently Asked Questions
    • Manage My Book of Business
      • Agent Dashboard
      • Manage Alerts
      • Contingent Commissions
      • Agent Monthly Commission
      • Create An Application
      • Make a Payment
      • Report an Incident
      • Policy Document Portal
      • View Billing History
  • Claimants
    • The Claims Process
    • Find a Medical Provider
    • Frequently Asked Questions
    • Forms & Resources
  • Providers
    • Find A Medical Provider
    • Medical Provider FAQs
    • Login / Register

Agent Forms

Audit

  • Audit Worksheet Release Form
  • Independent Contractor Affidavit
  • Independent Contractor Affidavit (Spanish)
  • Premium Audit Revision Request

Claims

  • IA-1 First Report of Incident
  • Direct Deposit
  • Direct Deposit (Spanish)
  • Average Weekly Wage Certification (AWW)
  • Medical Waiver & Consent Form (Form 106)
  • Notice of Designated Physician (Form 113)
  • Claimant Reimbursement Form (Form 114)
  • Job Analysis Form
  • W-9 Taxpayer Identification Number Request Form (IRS Website)

Other

  • Agency Internal Setup Form (for new agencies)
  • Agency Commission Direct Deposit Change Form
  • KEMI.com Administrator Designation Form
  • KEMI Logo Request Form

Underwriting

  • ACORD Agent/Broker of Record Change
  • Aviation Questionnaire
  • Employee Leasing Company Registration Form (EL-1)
  • Employee Leasing Lessee Information Form
  • Employee Leasing Supplemental Information Form
  • ERM-14
  • Coal Mine Census
  • Coal Mine Questionnaire
  • KEMI Direct Business Questionnaire
  • Lessee Information Form (EL-2)
  • Logging Questionnaire
  • No Loss Certification
  • Policy Cancellation Request Form
  • Sawmill Supplemental Application
  • Temporary Staffing Client Information Form
  • Temporary Staffing Supplemental Information Form
  • Trucking Owner / Operator Supplemental Information Form
  • Workers’ Compensation Experience Rating for Self-Insureds (ERM-6) with Instructions

 

Quick Links
  • Why Choose KEMI?
  • Make a Payment
  • Contact Us
About KEMI

KEMI is Kentucky's leading provider of workers' compensation insurance. We are rated A- (Excellent) by A.M. Best.

Learn more

AM Best Rating Services

Latest News
EKU substantially reduces annual premium with workplace safety program
04
Dec
KEMI enhances relationships with policyholders through Medcor
30
Nov
A.M. Best affirms KEMI’s A- Excellent Rating
22
Nov
Get Updates from KEMI

Each month, KEMI shares free safety news and resources for employers across Kentucky.

Sign Up

  • Privacy Policy
  • Secure Access Agreement
  • Open Records
  • Report Business Concerns
  • Certifications
Copyright 2023 © KEMI
  • Home
  • Employers
    • Employer Resources
      • How Workers’ Comp Works
      • Why Choose KEMI?
      • Find an Agent
      • Safety & Training
      • Claims Management
      • The Audit Process
      • Employer Forms
      • Frequently Asked Questions
    • Manage My Policy
      • View Policy Details
      • Manage Alerts
      • Make a Payment
      • Obtain Certificate of Insurance
      • Order Coverage Posters
      • Complete an Audit
      • Generate Loss Run
      • View Billing History
    • Manage My Claims
      • Report an Incident
      • Claim Detail Dashboard
      • Find a Medical Provider
      • Report Fraud
  • Agents
    • Agent Resources
      • How Workers’ Comp Works
      • Why Choose KEMI?
      • Rates
      • Commissions
      • Other States Coverage
      • Safety & Training
      • Claims Management
      • The Audit Process
      • Agent Forms
      • Frequently Asked Questions
    • Manage My Book of Business
      • Agent Dashboard
      • Manage Alerts
      • Contingent Commissions
      • Agent Monthly Commission
      • Create An Application
      • Make a Payment
      • Report an Incident
      • Policy Document Portal
      • View Billing History
  • Claimants
    • The Claims Process
    • Find a Medical Provider
    • Frequently Asked Questions
    • Forms & Resources
  • Providers
    • Find A Medical Provider
    • Medical Provider FAQs
  • About KEMI
  • Safety & Training
  • En Español
  • Careers
  • Contact
  • Kentucky's leading workers' comp provider