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.
| Name | Form | Description | File |
|---|---|---|---|
|
ACORD™ workers' compensation application form |
ACORD |
Use this form to apply for SAIF coverage. Please contact us for assistance. |
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|
Cancellation of election for coverage as a worker |
X-3000 |
To cancel personal election coverage for an owner, this form is to be completed by an authorized representative of the business. |
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Personal coverage application for nonsubject corporate officers |
X-1460 |
To elect coverage for a nonsubject corporate officer, this form is to be completed by an authorized corporate representative. |
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Personal coverage application for sole proprietors, nonsubject partners, or nonsubject limited liability company (LLC) members |
X-1461b |
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. |
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|
Designation of Corporate Officer Exemption form Construction, Timber Harvest, or Landscape Industries |
X-3267 |
To exempt a corporate officer from coverage, this form is to be completed by an authorized corporate representative. |
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Designation of Partner or LLC Member Exemption form Construction or Landscape Industries |
X-3327b |
To exempt a partner or LLC member from coverage, this form is to be completed by a partner or LLC member. |
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Confidential request for ownership information |
ERM-14 |
Use this NCCI form to notify SAIF of ownership and/or entity changes in your business. |
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Nondisabling Claims Reimbursement form |
F-3135 |
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. |
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|
Policyholder's Cancellation of Workers' Compensation Insurance |
X-773 |
To cancel your workers' compensation insurance policy, this form is to be completed by an authorized representative of the business. |
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Premium credit application |
X-948 |
This application is for policyholders or agents to complete. |