Worker's Compensation Line of Business

The purpose of the Worker's Compensation line of business form is to gather information specific to the policy to which you are attaching this line of business.

The Line of Business list is filtered by the Type of Business selected in the Basic Policy Information section, only if the Filter data entry and lines of business by Type of Business check box is also selected.

Part 1 Workers Compensation States

Click New (or Edit) and enter the following information. When finished, click Add (or Update). The updated information appears in the associated grid. To add multiple entries, repeat this procedure.

State	Select the states in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the applicant has operations.
Retro Rating Plan	Retrospective Rating Plans permits the adjustment of the final premium based on the actual premiums and losses of the applicant, subject to the plan's minimum and maximum premium limits. One to three year plans may be available. Check with the company for available plans.
# Years Retro in Effect	If the Retrospective Rating Plan applies, how long has it been in effect?
Anniversary Rating Date	Normally, the rates used are in effect on the effective date of the policy. NCCI manual rules require that the rates apply for a period of one year. If a policy is canceled or short-termed, the rating bureau requires the original effective date be considered the Normal Anniversary Rating Date for both rates and experience modifications. This is temporary and will last until the next renewal when the policy effective date will again determine the rates. This rule is intended to prevent wholesale cancellations by insureds and companies to take advantage of rate and/or rule changes. For canceled or short-termed policies, enter the original effective date.
Additional Company Information	Type any further company or state specific information that helps in underwriting this policy.
Additional Plan Information	Is the Insured a member of a Safety Group?: Indicate if the applicant is a member of a Safety Group. This field relates to the participating plan.
	Dividend Plan or Safety Group: Identify the specific plan or group of which the applicant is a member.
	Is Policy to be set on a Participating Basis?: Indicate Yes or No. A participating policy may result in reduced premiums through the payment of policyholder dividends declared by the insurer. Some policyholder dividends are based on actual experience of the applicant. Check with the company on plan availability.
Identification Numbers	Employer ID: Federal Employer ID Number (FEIN) assigned by the IRS to specifically identify the applicant. This number is required in most states before a policy can be issued. A separate FEIN may apply to each named insured. For individuals with no FEIN, use the Social Security Number.
	NCCI Id: A nine-digit number assigned to the applicant by the National Council on Compensation Insurance (NCCI). This number is required in most states before a policy can be issued. It also helps insure timely and accurate calculation of experience modification. The NCCI is a rating bureau operating in most states that also provides interstate experience rating for risks occurring in more than one state.
	Other Rating Bureau Id or State Employer Reg #: A state's rating bureau may assign a separate identification number if the applicant is subject to experience rating in an independent bureau state. In Minnesota, use this box for the applicant's unemployment account number, as required by the state. In New Jersey, use this box for the applicant's state employer registration number.

Part 2 Employers Liability

Enter the following information in the Part 2 Employers Liability section.

Workers Comp & Employers Liability, Employers Liability, Increased Employers Liability	Select the type of Employers Liability coverage you are entering.
Each Accident Limit, Disease Policy Limit, Disease Each Employee	Type the applicable limits for the coverage you are entering.
Deductible	Enter the amount of the deductible.
Deductible Type	Select the deductible type from the list.
Applies To	Select the coverage(s) to which the deductible applies.
Liability Coverage Type	From the list, select whether this is primary or excess liability coverage.
Coverage Basis	Select either coverage by occurrence or claims made.
Other Coverages	Classification Total Premium: Enter the total premium for all classifications or click Calculate to have AMS360 figure this amount for you based on the entries made in the Classification/Rating Information section.
	Calculate: Click to have AMS360 figure the Classification Total Premium amount for you based on the entries made in the Classification/Rating Information section.
	Coverage: Select the coverage(s) that apply and/or select them from the list.
	Factor: Type the factor used to calculate the premium for the coverage.
	Factored Premium: Type the premium.
	Limit: Type the coverage limit.
	Deductible: Type the applicable deductible amount.
	Deductible Type: Select the type of deductible from the list.
Total Estimated Annual Premium	Enter the total premium for coverages entered in this section or click Calculate to have AMS360 add the amounts entered for the individual coverages in this section and display the total in the Total Estimated Annual Premium field.
Calculate	Click to have AMS360 add the amounts entered for the individual coverages in this section and display the total in the Total Estimated Annual Premium field.
Additional Coverage Information	Type any additional information that applies to this coverage.

Classification/Rating Information

Forms

Form #	Policy form number or company form designation for the type of policy/coverage desired.
Edition Date	Enter the Edition Date that applies to this form (MM/YYYY)
Form Name	Enter the name of the form.
Description	Enter the form description.
Eff/Exp Date	Enter the effective and expiration dates for the form.

Some fields may not be available depending on the type of line of business.

Form Mapping

See where data flows to the ACORD and other forms.

What's Next?

Do you need to create and print Applications? See eForms Manager for more information.

State	Select the states in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy.
Other States Insurance Coverage	Use this option to request optional United States Longshoremen's & Harbor Worker's (USL&H) coverage and Voluntary Compensation coverages. Select whether the coverage is included or excluded.