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Forms for Agents
Underwriting Guidelines
Service Lloyds Underwriting Guidelines
Underwriting Forms
DWC-81: Agreement Between General Contractor and Subcontractor To Provide Workers' Compensation Insurance
DWC 85: Agreement Between General Contractor and Subcontractor to Establish Independent Relationship
Contractor Questionnaire
TDI: Deductible Notice of Election
TDI: Request for Information Form
New Venture/Subscriber Form
USL&H Supplemental Application
ACORD Forms
ACORD 25: Certificate of Liability Insurance
ACORD 36: Agent/Broker of Record Change
ACORD 130: Workers' Compensation Application
ACORD 130 Instructions
ACORD 175: Commercial Policy Change Request
CorCare® Network Forms
Employee Acknowledgement Form
(English & Spanish)
Employer Log / Register
Claims: TDI Forms
DWC-1: Employer's First Report of Injury or Illness Form
DWC-3: Employer's Wage Statement
DWC-3S: Employer's Wage Statement (Spanish)
DWC-3ME: Employee's Multiple Wage Statement
DWC-3MES: Employee's Multiple Wage Statement (Spanish)
DWC-6: Supplemental Report of Injury Form
DWC-7: Non-covered Employer's Report of Occupational Injury or Illness
DWC-73: Work Status Report
Miscellaneous Forms
Sample Modified Work Duty Agreement
Accident Investigation Form