WC 00 00 01 A-Information Page-Workers Compensation And Employers Liability Insurance Policy

WC 00 00 01 A–INFORMATION PAGE–WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

(December 2023)

 

 

INTRODUCTION

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

ITEM 1

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.

ITEM 2

The policy effective and expiration dates

Note: The date and time are based on the named insured’s mailing address.

ITEM 3 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:

 

Example: A group of employees at Credible Manufacturing are severely injured. Even though they are eligible for workers compensation, they sue Credible because of Credible’s egregious negligence.

Scenario 1: The injuries are due to a poorly maintained overhead crane collapsing and falling on them. The maximum to pay the sum of all awarded sums is whatever each accident limit is provided.

Scenario 2: The injuries are due to disease contracted by the employees due to poorly controlled harmful chemicals at the plant. The “each employee” will limit how much each employee can be paid, and the policy will limit how much the sum of all employee payments can be made for the same disease.

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.

 

Example: Marion Enterprises has plants in North Carolina and Michigan. All sales are conducted through manufacturers’ representatives, but employees may travel to see customers or vendors. Marion lists North Carolina and Michigan in Section 3. A. and then enters, “All states except NC, MI, ND, OH, WA, and WY” in Section 3 C.

Marion decides to eliminate manufacturers’ representatives and instead employ salespersons who live in 15 different states. The salespersons will operate out of their homes and travel regionally but primarily in their home state. Marion must then list the 15 states where those salespersons work in Section A and remove those states from Section C.

Scenario 1: Marion employs the salespersons on 1/1/2023, which happens to be its effective date. Coverage is available for employees in those 15 states until 1/30/2023 unless the insurance company is notified prior to 1/30/2023.

Scenario 2: Marion employs the salesmen as of 2/1/2023, which is 30 days after its effective date. Coverage is available for employees in those 15 states until 1/1/2024

Section D–Endorsements or Schedules

Endorsements or schedules 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.

ITEM 4

This is the premium section. It must be arranged as follows:

o    Premium Basis

o    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.

o    Rate per $100 of Remuneration

o    Estimated Annual Premium