Field

What is this?

State

Enter 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 cancelled 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 cancelled or short-termed policies, enter the original effective date.

Additional Company Information

Enter any further company or state specific information that helps in underwriting this policy.

Additional Plan Information

Identification Numbers

Table2

Column Heading

Workers Comp & Employers Liability

Choose the type of Employers Liability coverage you are entering.

Employers Liability

Increased Employers Liability

Each Accident Limit

Enter the applicable limits for the coverage you are entering.

Disease Policy Limit

Disease Each Employee

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

Choose either coverage by occurrence or claims made.

Other Coverages

Total Estimated Annual Premium

Enter the total premium for coverages entered in this section or click Calculate to have AMS 360 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

Enter any additional information that applies to this coverage.

Field

What is this?

State

Enter 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.

Field

What is this?

State

Enter 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.

Field

What is this?

State

Select a state from the list.

Only states entered in Part 1 Workers Compensation States appear in this list.

Location #

Location number corresponding to the locations entered previously.

Class Code

Code that best describes the applicant's business. It is the business of the employer, not the individual employee, that is being classified. Use a rating manual to determine the code. Rating bureaus may exercise control over classification assignment.

Categories, Duties, Classifications

A single class code can include several related descriptions of activities/operations. It is extremely important to enter the specific classification description or, at least a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid mis-classifying the operations.

Rating Basis

Select the method used to determine the rate. Choose from the list.

Exposure (Remuneration)

The amount at risk.

Rate

The rate at which the coverage is calculated.

Premium

Enter the cost of this coverage.

If you select a Rating Basis, Exposure and Rate in this section, AMS 360 calculates the premium for you.

Number of Employees

Field

What is this?

Name

Select a name from the list or type the name of the partner, executive officer, or relative so you can indicate whether or not the individual is covered by the policy.

Enter the information as you want it to appear on forms. Include punctuation.

Individual Coverage Status

Select whether the individual is included or excluded from coverage on this policy.

Title/ Relationship

Enter the individual's title within the organization or relationship to the owners of this organization.

Duties

Briefly describe the duties of the individual.

Date of Birth

Enter the individual's date of birth or select it from the Date Picker.

% of Ownership

The percentage of ownership the individual has in the organization, if applicable.

Class Code

Enter the class code for individuals who are being included based on the duties listed.

Remuneration

Estimated annual remuneration for individuals who are being included. Minimum or maximum remunerations may apply based on state laws.

Field

What is this?

Name

Select a name from the list or type the name of the partner, executive officer, or relative so you can indicate whether or not the individual is covered by the policy.

Enter the information as you want it to appear on forms. Include punctuation.

Individual Coverage Status

Select whether the individual is included or excluded from coverage on this policy.

Title/ Relationship

Enter the individual's title within the organization or relationship to the owners of this organization.

Duties

Briefly describe the duties of the individual.

Date of Birth

Enter the individual's date of birth or select it from the Date Picker.

% of Ownership

The percentage of ownership the individual has in the organization, if applicable.

Class Code

Enter the class code for individuals who are being included based on the duties listed.

Remuneration

Estimated annual remuneration for individuals who are being included. Minimum or maximum remunerations may apply based on state laws.

Button

What is this?

Set all "No"

Click to answer all questions No. You can then change individual answers as necessary.

Field

What is this?

Coverage Level

Coverage

Select the coverage from the list.

Sort Order

Enter the order that this coverage should appear in the grid and on forms.

Limit 1
Limit 2
Limit 3

Enter the single or split limits that apply.

Exposure

The amount at risk.

Rate

The rate at which the coverage is calculated.

Premium

Enter the cost of this coverage.

Deductible Information

Miscellaneous Information

Enter any additional information that applies to this coverage.

Group/Field

What is this?

Filter

Use these selections to find Additional Interest data that has already been entered in the Additional Interest Setup.

Type

Select the term that best describes the nature of the insurable interest in the policy item. Selections in this list are maintained in List Setup.

Name

Type an additional interest name or choose an interest from the list. Names are added to this list through Additional Interest Setup.

Enter the name exactly as the interest requires it to appear on the Evidence of Property, Binder, Certificate, or other forms.

Contact

If the interest is a business, enter the name of the contact person here.

Address

Enter the information as you want it to appear on forms and correspondence, including capitalization and punctuation.

City

State

Zip

Phone Numbers and Email

Write Additional Interest to Setup

Check this box to save the contact information to the Additional Interest Setup. Once you click save, this Additional Interest can be selected from the Filter lists for any Line of Business.

Interest

Certificate

Policy

Loan Information

Interest in Item

Field

What is this?

Form #

Policy form number or company form designation for the type of policy/coverage desired.

Edition Date

Enter theEdition Datethat applies to this form.

Form Name

Enter the name of the form.

Description

Enter the form description.