Agent Forms

Audit

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

Claims

• IA-1 First Report of Injury
• Direct Deposit
• Direct Deposit (Spanish)
• Average Weekly Wage Certification (AWW)
• Medical Waiver & Consent Form (Form 106)
• Notice of Designated Physician (Form 113)
• Injured Worker 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)
• ERM-14
• Coal Mine Census
• Coal Mine Questionnaire
• KEMI Direct Business Questionnaire
• Lessee Information Form (EL-2)
• Logging Questionnaire
• No Loss Certification
• Owner / Operator Supplemental Information Form
• Policy Cancellation Request Form
• Sawmill Supplemental Application
• Temporary Staffing / Employee Leasing Client Information Form
• Temporary Staffing / Employee Leasing Supplemental Application
• Workers’ Compensation Experience Rating for Self-Insureds (ERM-6) with Instructions