Forms and Publications

For the convenience of our customers, Chesapeake Employers has built a listing of downloadable PDF forms that you can print as needed. Each of the forms listed includes a brief description of what the form is to be used for. Some are available in Spanish.

Policyholder Forms

Electronic Funds Transfer PDF

Chesapeake Employers has available the ability to do electronic funds transfer (EFT). From the Policy Activity/Make Payment link under the e-Services menu, policyholders can have premium payments deducted from their checking or savings accounts. This is a one-time deduction and not an automatic debit. By selecting EFT when making a payment, and entering the information printed on your bank account checks, policyholders now have another way to make premium payments.

Officer Exclusion Form PDF

This form is utilized to exclude an officer(s) from a Workers' Compensation Policy. The rules and regulations vary as to when this form may be utilized, so please contact your insurance agent or your Chesapeake Employers' Underwriter to discuss. After completion of the form, (including signatures), please forward the original form (no photocopies or faxes please) to your agent or Chesapeake Employers' Underwriter. We will be pleased to forward your original to the Workers' Compensation Commission as a courtesy and update your policy.

Sole Proprietor's Status as a Covered Employee Form PDF

This form is to provide coverage to a Sole Proprietor subject to our minimum payroll. Please call your agent or Chesapeake Employers' Underwriter for a detailed explanation. We will be pleased to forward your original (no photocopies or faxes please) to the Worker's Compensation Commission as a courtesy and update your policy.

PRIMARY: Accident Investigation/Reporting and Injured Worker Forms

Accident Investigation Forms - English PDF
Accident Investigation Forms - Spanish PDF

The injured employee, supervisor and any witnesses to the accident, should complete and sign these forms. Keep a copy of the completed forms for your records. The completed forms should then be mailed or faxed to your Chesapeake Employers' Claims Adjuster. Obtaining signed statements as soon as possible following an accident ensures that you, the employer have an accurate account of how the injury occurred.

ACORD 4 First Report of Injury PDF

(Important) We strongly recommend employers report the injury via our toll-free injury reporting hotline or using our online injury reporting service. Reporting the injury via our hotline or using our online injury reporting service are more convenient and faster than manually completing the form. If you choose to manually complete the Acord Employer's First Report of Injury, please submit the completed form either by fax to 410-494-2002 or send by mail to: Chesapeake Employers' Insurance Company, 8722 Loch Raven Boulevard, Towson, MD 21286.

Fraud Referral Reporting Form PDF (Coming soon)

A reporting form for information concerning possible fraudulent activity against Chesapeake Employers.

Temporary Prescription Services ID Form PDF

When an employee requires medical treatment and needs prescriptions filled for a work-related injury, provide the employee with a copy of this form to take to the pharmacy. When this completed form is presented to the participating pharmacy, the prescriptions are filled with no out-of-pocket expenses for the employee.

Statement of Wage Information Form Chesapeake Employers PDF

A form 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.

When an Injury Occurs Flyer - English PDF
When an Injury Occurs Flyer - Spanish PDF

A one-page step-by-step reminder guide for reporting an injury immediately and for obtaining medical care. Please fill in the medical provider's name of your choice on the flyer. Please copy the reminder flyer as needed and distribute or post for supervisory staff.

SECONDARY: Accident Reporting and Injured Worker/Claimant Forms

Claimant Authorization Agreement for Direct Payments PDF

Claimants who would like to have their workers' compensation benefit checks directly deposited to their personal bank accounts must complete this form. Please note: Chesapeake Employers can only pay permanent partial disability benefits biweekly by direct deposit on request. The weekly benefit for temporary total disability is NOT available for direct deposit. Please consult your Chesapeake Employers' Claims Adjuster for more information.

Medical Travel Expense Form PDF

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.

Other Forms

Direct Deposit for Medical Providers PDF (Electronic Fund Transfers)

EFT enables you to receive reimbursement for services provided to injured workers directly into your bank account. To enroll in Direct Deposit-EFT, simply download the Direct Deposit form and mail or fax (410-494-2088) to Chesapeake Employers, attention Finance Department. For more information contact the Customer Service Call Center at 1-800-264-4943.

Job Analysis Form for Return to Work Program PDF

All "jobs/positions" in your business should have a job analysis form completed and on file. The information on this form is valuable in helping the claims adjuster and treating physician better understand the job duties and physical demands of an injured worker. This form is especially important for determining a temporary modified job function for the employee.

Job Safety Analysis (JSA) form – A Job Safety Analysis (JSA) should be performed for all operations, and especially for those that result in employee injury or have the potential for injury. A JSA can also be used to analyze work practices for effectiveness and to map job safety procedures. A JSA has four basic steps: (1) Select the job to be analyzed; (2) Break the job down into steps; (3) Identify the hazards or potential hazards for each step; and (4) Develop controls or solutions for each of the hazards or potential hazards.

Job Safety Analysis (JSA) Sample - pdf
Job Safety Analysis (JSA) Form - fillable pdf

Workers' Compensation Commission Forms

eServices LoginFind a Local AgentSafety UniversityClaims Management Expertise

Chesapeake Employers' Insurance Company •  Formerly the Injured Workers' Insurance Fund • 8722 Loch Raven Blvd. • Towson, MD 21286   410-494-2000  1-800-264-4943   Privacy Policy and Data Security