Assigned Risk Reinsurance Pool
Annual Premium Call
Section 4.03 of the Articles of
Administration for the Indiana Assigned Risk Reinsurance Pool (“Indiana Pool”)
provides that each Member shall report to the Plan Administrator, in the form
and manner prescribed by the Plan Administrator, the Net Premiums Written by
such Member during each calendar year. FORM IN-10 is used for this purpose and
must be filed even if no workers compensation premium was written in
The Take-Out Credit Program continues in effect for the Indiana Pool. To receive credits you must be enrolled with NCCI. See additional instructions below.
ONLINE SUBMISSION of FORM IN-10 is required. Please do not mail, email, or fax a copy of your submission. If your contact information has changed, FORM IN-3 should also be submitted.
All necessary forms and instructions are provided below.
Please note that Adobe Reader is required to view and print the instructions.
If you have any questions, please call 601-977-9456.
Click the link below to complete your submission online. Once the online FORM IN-10 appears, complete the appropriate fields. Attach Statutory Page 14 (in PDF format) with your online submission, by clicking the "Choose File" button located in the "Statutory Page 14" section. If you would like a copy of your online submission, please Print it before clicking the "Submit Form" button.
Online Submission: FORM IN-10
Member Company Contact
Form IN-3 should be submitted if your contact information has changed.
Use the link below to download FORM IN-3 and open the document. Use “Save As” to save a copy of the form as a Microsoft Word document to the appropriate location on your computer. Fill in the applicable information using the Tab key or arrow keys to move from field to field.
“Save” your changes and email the completed form to the ICRB (c/o CIS), using the following email address: INdata@CompInsServices.com.
Please note that Adobe Reader is required to view and print these instructions.