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
Prime Health Services Network Forms
- Employee Acknowledgement Form (English)
- Employee Acknowledgement Form (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