WC 00 00 01 A-Information Page-Workers Compensation and Employers Liability Insurance Policy is the workers compensation equivalent of the declarations used with other lines of insurance. It is different because NCCI establishes the rules as to how the information is to be provided and presented. These rules provide consistency with state and National Council of Compensation Insurance, Inc. (NCCI) reporting requirements. While the sequence of Items 1 through 4 on the Information Page cannot be changed (with a limited exception for Item 3. D. explained below), the format of each item may be rearranged where allowed.
INSURANCE COMPANY IDENTIFICATION INFORMATION
The following information must be entered in the section prior to Item 1:
- The name of the insurance company providing the coverage
- The insurance company’s NCCI five-digit Company Code Number
- The insurance company’s mailing address
- The policy number
- The word new or the prior policy number
The exact name of each insured employer and its mailing address must be entered in the space provided. The insured employer must be identified as an individual, partnership, corporation, or another legal entity, such as an association, joint venture, or limited liability company. The addresses or locations of all other workplaces, if any, in addition to the mailing address, must also be entered in the space provided.
Note: An endorsement that lists additional locations may be attached if the space provided is too small to list them all.
The policy effective and expiration dates.
Note: The date and time are based on the named insured’s mailing address.
Section A-Workers Compensation Insurance
This section provides a listing of states in which Workers Compensation Insurance and Employers Liability Insurance is provided are listed.
Note: In rare circumstances no states are to be listed. If such a case, the word NONE should be entered in order to prevent any confusion.
Section B-Employers Liability Insurance
This section applies to only Part Two, Employers Liability Insurance and applies to each state listed in Section A above. The limits of the insurance company’s liability under this section are listed and expressed as:
- Bodily Injury by Accident: $__________each accident
- Bodily Injury by Disease: $__________policy limit
- Bodily Injury by Disease: $__________each employee
Section C-Other States Insurance
This section applies to Part Three-Other States Insurance. The states listed in this area are ones where the named insured MIGHT have work but in which the named insured has no existing locations or known exposures. Coverage applies to employees who are injured in any of these listed states.
There is an exception to coverage. If the named insured has work in a listed state on the effective date of the policy, there is no coverage in that state unless the insurance company is notified of that work within 30 days.
None of the states that are listed in Section A and no monopolistic state can be entered in this section.
Section D-Endorsements or Schedules
Endorsements or schedules that are attached to the policy at inception are to be entered using the standard eight-character identification number and the alpha character version identifier where applicable.
This is the premium section. It must be arranged as follows:
- Classification(s) and corresponding code number(s)
- Premium Basis
- Total Estimated Annual Remuneration. Note: This is NOT limited to payroll. It may include other types of remuneration to which the parties have agreed upon such as room and board.
- Rate per $100 of Remuneration
- Estimated Annual Premium
- Premium for increased limits, Part Two
- Total premium (The sum of the classifications annual premium plus the increased limits premium)
- Experience Modification Factor
- Scheduled Rating Modification Factor
- Premium that has been modified by experience and schedule rating modification
- Other premium charges that may apply
- Total Estimated Standard Premium
- Premium Discount
- Expense Constant Charge
- Total Estimated Premium
- State specific surcharges
- Total Estimated Cost
- Minimum Premium
- Deposit Premium