Reporting Forms


The forms below can be used to file quarterly reports.  Reports and any assessments due must be received, or postmarked by the United States Postal Service, no later than the 30th day of the following month.  Please note that a company's postage meter with date is not an acceptable form of USPS postmark.

Please make sure submitted reports include year and quarter for which you are filing and that you select Original or Amended in the upper right hand corner.


Reminder: E-File/E-Pay is now available and can be accessed here.


Download Quarterly Reporting Forms


Insurance Company Quarterly Premium Report.pdf [52K]

Group Self Insurer Quarterly Premium Report.pdf [18KB]

Self Insurer Quarterly Premium Report.pdf  [15KB]

Severed Coal Assessment Report.pdf [15kb]