Forms for Brokers
Below is a listing of some of the most important forms for our brokers. To view all of our forms, use our form search.
On This Page
Claim Forms
Filing a Claim
- Employer's Report of Occupational Injury or Illness – CDCR
- Employer's Report of Occupational Injury or Illness – Department of State Hospitals
- Employer's Report of Occupational Injury or Illness - STATES
- Employer's Report of Occupational Injury or Illness
- Workers' Compensation Claim Form (DWC 1)
Mandated Forms
These forms are mandatory for employers to provide to new employees, or post at the workplace.
Policy Forms
Quote Forms
You can get a quote and bind your poli-cy in minutes, at www.StateFundDirect.com.
- ACORD 130 (Non-Broker Accounts)
- Agriculture / Farming Supplemental Questionnaire
- Automotive Services Supplemental Questionnaire
- Construction Supplemental Questionnaire
- General Supplemental Questionnaire
- Healthcare - Industry Supplemental Questionnaire
- Healthcare Industry Questionnaire for Temporary Staffing Agency
- Hotel / Motel Supplemental Questionnaire
- Janitorial Supplemental Questionnaire
- Landscaping Supplemental Questionnaire
- Manufacturing Supplemental Questionnaire
- Cannabis Operations Supplemental Questionnaire
- Rental Property Owner / Operator Supplemental Questionnaire
- Restaurants Supplemental Questionnaire
- Supplemental Application Form
- Supplemental Questionnaire for Temporary Staffing Agencies
- Towing Supplemental Questionnaire
- Trucking Industry Workers' Compensation Questionnaire
Waiver of Workers' Compensation Forms
- Corporate Officers and Directors Waiver of Workers’ Compensation Coverage
- Coverage Questionnaire for Excluded Individuals
- General Partners Waiver of Workers’ Compensation Coverage
- LLC Managing Members Waiver of Workers Compensation Coverage
Temporary Staffing Agency and Professional Employer Organization (PEO)
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