Forms & Publications

Complete this form if you are looking to use an electronic funds transfer (EFT) in order to make a payment online or through our customer service department. 

This form is used for excluding an officer(s) in your workers' compensation policy. Please coordinate completion and submission of this form with your agent or Chesapeake Employers’ Underwriter. 

This form is used to provide coverage to a Sole Proprietor subject to our minimum payroll. Please call your agent or Chesapeake Employers' Underwriter for a detailed explanation.

This form is used for including an officer(s) in your workers' compensation policy. Please coordinate completion and submission of this form with your agent or Chesapeake Employers’ Underwriter. 

Claimants who would like to have their workers' compensation permanency benefit checks directly deposited (bi-weekly) to their personal bank accounts must complete this form.

Chesapeake Employers' claimants are entitled to reimbursement for travel expenses for medical treatment resulting from a work injury. This completed form along with appropriate receipts are required for reimbursement.

IWIF claimants are entitled to reimbursement for travel expenses for medical treatment resulting from a work injury. This completed form along with appropriate receipts are required for reimbursement.

The ACORD 4 form is intended to be used for the employers' first report of injury.  We strongly recommend employers report the injury via our toll-free injury reporting hotline or by using our online injury reporting service. 

The injured employee, supervisor, and any witnesses to the accident, should complete and sign these forms and return them to the Chesapeake Employers’ claims adjuster.

When an injured worker requires medical treatment and needs prescriptions filled for a work-related injury, the employee may take a copy of this completed form to the pharmacy to receive prescriptions with no out-of-pocket costs.

This form is used to list the gross weekly earnings paid to the injured worker for the 14 weeks immediately prior to the date/week of the accident for the purpose of calculating benefits.

EFT enables medical providers to receive reimbursement for services provided to injured workers directly into your bank account.

All "jobs/positions" in your business should have a job analysis form completed and on file to assist in identifying return-to-work opportunities.

This form is intended to capture the physical capabilities of an injured worker, as determined by a physician.

This document will evaluate the injured employee's return to his/her transitional job duties and should be completed by the employer and the employee.