FORMS

Underwriting Forms Application for Coverage - Provides basic underwriting information to be completed and returned to review an account for USSIC PEI coverage consideration. Transportation Questionnaire - Provides additional underwriting information specific to transportation accounts. DWC Form-5 Information - One of two Texas forms that must be completed and returned to opt out of Workers Compensation coverage. DWC Form-7 Information - One of two Texas forms that must be completed and returned to opt out of Workers Compensation coverage. How to Bind Occupation Accident Information - Steps required to bind an Occupational Accident policy. WC Rejection Notice to be Posted (English) - Notice to be posted if/when an insured opts out of Workers Compensation coverage. WC Rejection Notice to be Posted (Spanish) Acknowledgement of Safety Orientation - Form to be signed by employee acknowledging that he or she has received applicable safety orientation information.

Claims Forms First Report of Injury (English) - This document is required to begin the claims handling process. The First Report of Injury provides USSIC notice that a workplace injury has occurred. It is critical that this document be completed and faxed or emailed to USSIC within 24 hours of the loss. First Report of Injury (Spanish) Employee Statement (English) - Form to be completed by the employee in the event of an on-the-job injury. Employee Statement (Spanish) Supervisor's Report (English) - Form to be completed by the supervisor in the event of an on-the-job injury. Supervisor's Report (Spanish) Witness Statement (English) - Form to be completed by the witness, if any, in the event of an on-the-job injury. Witness Statement (Spanish) Medical Authorization (English) - Form to be signed by the employee in the event of an on-the-job injury. Medical Authorization (Spanish) Declined Medical Treatment (English) - Form to be signed by the employee if he/she declines treatment in the event of an on-the-job injury. Declined Medical Treatment (Spanish) Wage Statement (English) - Form to be completed if an employee is anticipated to be off of work for more than seven days to determine the employee's average weekly salary. Wage replacement will be 75% of the employee's average weekly salary, up to a maximum of $600 per week. Wage Statement (Spanish)

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