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Downloadable Forms

Click on the form you need below and you can use your tab key to type in each field. When you're done, print the document, sign it if necessary and send it in!

Don't forget you can register to use our online services to submit First Reports of Injury and Policy Applications!

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Audit Forms
 
Audit Worksheet Release Form
Independent Contractor Questionnaire
Independent Contactor Questionnaire (Spanish)
Trucking Independent Contractor Questionnaire
Premium Audit Dispute Requirements
 
Claims Forms
 
Average Weekly Wage Certification (AWW)
Direct Deposit
Direct Deposit (Spanish)
IA-1, First Report of Injury
Injured Worker Reimbursement Form (Form 114)
Job Analysis Form
Medical Waiver & Consent Form (Form 106)

Notice of Designated Physician (Form 113)

Request for Bill Status
Request for Copy of Explanation of Review
W-9 Taxpayer Identification Number Request Form (IRS Website)
 
Underwriting Forms
 
Aviation Questionnaire
Employee Leasing Company Registration Form (EL-1)
ERM-14
Coal Mine Census
Coal Mine Questionnaire
Lessee Information Form (EL-2)
Logging Questionnaire
No Loss Certification
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
 
Other Forms
 

 
 

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Kentucky Employers' Mutual Insurance  250 W. Main St., Ste. 900 Lexington, KY 40507
859-425-7800