For an explanation of each payment reason, click the appropriate option below.
*THE FEE FOR AN E-CHECK IS $0.15. THE FEE FOR A CREDIT CARD PAYMENT IS $0.40 + 1.96%.
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Second Injury Fund Assessment
- All carriers and self-insured employers operating in Indiana are subject to the Second Injury Fund assessment. For your convenience, payments may be made through this electronic interface. Once completed, please print and attach your receipt to the appropriate certification form and mail both to our offices at the address below.
402 W WASHINGTON ST, RM W196
INDIANAPOLIS, IN 46204
- All carriers and self-insured employers operating in Indiana are subject to the Second Injury Fund assessment. For your convenience, payments may be made through this electronic interface. Once completed, please print and attach your receipt to the appropriate certification form and mail both to our offices at the address below.
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Self-Insurance Application Fee
- All employers wishing to gain self-insured status must remit an application fee. For your convenience, payments may be made through this electronic interface. Once completed, please print and attach your receipt to the application form and mail both to our offices at the address below.
402 W WASHINGTON ST, RM W196
INDIANAPOLIS, IN 46204
- All employers wishing to gain self-insured status must remit an application fee. For your convenience, payments may be made through this electronic interface. Once completed, please print and attach your receipt to the application form and mail both to our offices at the address below.
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Self-Insurance Renewal Fee
- All employers wishing to maintain their self-insured status must remit a renewal fee. For your convenience, payments may be made through this electronic interface. Once completed, please print and attach your receipt to the renewal form and mail both to our offices at the address below.
402 W WASHINGTON ST, RM W196
INDIANAPOLIS, IN 46204
- All employers wishing to maintain their self-insured status must remit a renewal fee. For your convenience, payments may be made through this electronic interface. Once completed, please print and attach your receipt to the renewal form and mail both to our offices at the address below.
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Self-Insurance Late Fee
- Failure to timely submit a renewal application and the related fee will result in a late fee. For your convenience, payments may be made through this electronic interface. Once completed, please print and attach your receipt to the renewal form and mail both to our offices at the address below.
402 W WASHINGTON ST, RM W196
INDIANAPOLIS, IN 46204
- Failure to timely submit a renewal application and the related fee will result in a late fee. For your convenience, payments may be made through this electronic interface. Once completed, please print and attach your receipt to the renewal form and mail both to our offices at the address below.
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Payment for Copies
- Pursuant to State regulations, a copying fee of $0.10 per page applies to any and all records reproduced for public usage. As such, you have received a notice from us indicating the amount owed for your recent reproduction request. For your convenience, payments may be made through this electronic interface.
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Civil Penalties
- Pursuant to IC 22-3-4-15, certain penalties may be assessed when employers and/or their agents are found to be non-compliant with the laws pertaining to Worker's Compensation. As such, you have received a notice from us detailing both the reason for and the amount of the penalty being levied. For your convenience, payments may be made through this electronic interface.
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Mediation Fee
- The Worker's Compensation Board of Indiana provides mediation services to parties wishing to informally resolve a dispute. This service is provided for nominal fee. Such fee is due, at the latest, two business days prior to the mediation. You have received notice that payment is due. For your convenience, payments may be made through this electronic interface.
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Failure to Provide Proof of Coverage
- Pursuant to IC 22-3-2-22, certain penalties may be assessed when employers are found to be non-compliant with the laws pertaining to an employer's obligation to carry Worker's Compensation coverage. As such, you have received a notice from us detailing both the reason for and the amount of the penalty being levied. For your convenience, payments may be made through this electronic interface.
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Provider Application Fee
- All balanced bill provider fee applications must be accompanied by a $60 filing fee. Balanced bill provider fee applications received since 7/1/2011 are subject to this fee and will not be processed unless accompanied by said payment. For your convenience, payments may be made through this electronic interface. Once completed, please print and attach your receipt to the form and mail both to our offices at the address below.
402 W WASHINGTON ST, RM W196
INDIANAPOLIS, IN 46204
- All balanced bill provider fee applications must be accompanied by a $60 filing fee. Balanced bill provider fee applications received since 7/1/2011 are subject to this fee and will not be processed unless accompanied by said payment. For your convenience, payments may be made through this electronic interface. Once completed, please print and attach your receipt to the form and mail both to our offices at the address below.
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Workers Comp Policy Fee
- A 2013 change in Indiana law requires carriers to pay $2 for each workers' compensation policy written in Indiana annually. You have received an electronic notice detailing the amount due for each company you represent. Please note the amount owed by the individual carriers and remit a separate payment and form for each. For your convenience, payments may be made through this electronic interface. Once completed, please print and attach your receipt to the completed form and mail both to our offices at the address below.
402 W WASHINGTON ST, RM W196
INDIANAPOLIS, IN 46204
- A 2013 change in Indiana law requires carriers to pay $2 for each workers' compensation policy written in Indiana annually. You have received an electronic notice detailing the amount due for each company you represent. Please note the amount owed by the individual carriers and remit a separate payment and form for each. For your convenience, payments may be made through this electronic interface. Once completed, please print and attach your receipt to the completed form and mail both to our offices at the address below.