| Endorsement Name | Form No. | Description / Notes |
| Workers Compensation and Employers Liability Policy | WC 00 00 00 A | NCCI policy form |
| Workers Compensation and Employers Liability Policy Information Page & Extensions | WC 00 00 01 A | Declaration Page with standard information. |
| Defense Base Act Coverage Endorsement | WC 00 01 01 A | Extends USL&HW-level benefits to civilian employees or civilian contractors working on military bases outside the continental US (includes Alaska & Hawaii). Removes exclusion #8, the Defense Base Act exclusion from the employers' liability coverage wording. |
| Federal Coal Mine Health and Safety Act Coverage Endorsement | WC 00 01 02 B | Extends WC and EL benefits to employees as per Federal limits and guidelines to employees that contract “Black Lung." |
| Federal Employers' Liability Act Coverage Endorsement | WC 00 01 04 A | Workers' Compensation coverage does not apply in any state listed in the FELA Coverage Endorsement. Coverage is subject to Federal guidelines and requirements to garner protection. Exclusion “9" is removed. Employers' Liability coverage is extended to the states and up to the limits specified by the endorsement. No each employee “bodily injury by disease" limit, only a disease aggregate limit. |
| Longshoremen's and Harbor Workers' Compensation Act Coverage Endorsement (aka USL&HW endorsement) | WC 00 01 06 A | Extends / raises statutory WC benefits to comply with the benefits required by the USL&HW Act as specified by the Federal government. Rates may be higher to account for the increased benefits. Removes the USL&HW exclusion (within exclusion “8") from the employers' liability coverage wording. |
| Nonappropriated Fund Instrumentalities Act Coverage Endorsement | WC 00 01 08 A | Extends USL&HW-level benefits to civilian employees working on military bases within the continental US removes the Nonappropriated Funds exclusion (within exclusion “8") from the employers' liability coverage wording. |
| Outer Continental Shelf Lands Act Coverage Endorsement | WC 00 01 09C | Extends USL&HW-level benefits to workers on fixed structures located outside of territorial waters but within Outer Continental Shelf exclusion (within exclusion “8") from the employers' liability coverage wording. |
| Migrant and Seasonal Agricultural Worker Protection Act Coverage Endorsement | WC 00 01 11 | Deletes exclusion #12 from the Employers' Liability coverage (Part Two). |
| Maritime Coverage Endorsement | WC 00 02 01 B | Extends benefits to the limits required by maritime or admiralty law (Jones Act or DHSA included). Removes exclusion “10." Adds two exclusions: no coverage if P&I coverage and no coverage for transportation, maintenance and cure unless a premium is paid. |
| Voluntary Compensation Maritime Coverage Endorsement | WC 00 02 03 | WC 00 02 01A must first be attached. Extends WC coverage to masters and members of a crew when such is not required by law. Extends employers' liability coverage to masters and members of the crew when not required by law to provide coverage. |
| Alternate Employer Endorsement | WC 00 03 01 A | Designed to extend coverage when employees are considered the “borrowed servants" of a special employer. It is attached to the direct employer's policy, naming the special employer thus extending protection from the employer's policy to the putative employer. |
| Designated Workplaces Exclusion Endorsement | WC 00 03 02 | Use to exclude designated workplaces but only when proper and allowable in the law. |
| Employers' Liability Coverage Endorsement | WC 00 03 03 C | Extends employers' liability coverage to monopolistic states (ND, Ohio, Wash. And Wyo.). |
| Insurance Company as Insured Endorsement | WC 00 03 04 | Limits coverage to the insurance carrier's employees only. |
| Joint Venture as Insured Endorsement | WC 00 03 05 | Limits coverage exclusively to employees of the joint venture. Policy does not provide coverage for employees of the members of the joint venture. |
| Medical Benefits Exclusion Endorsement | WC 00 03 06 | Makes the insured solely responsible for paying medical benefits. Used mainly by self-insurers. |
| Partners, Officers and Other Exclusion Endorsement | WC 00 03 08 | Used for individuals considered an employee by law (varies by state) yet chooses to exclude themselves from the law and the benefits available from WC coverage. Exclusion can be accomplished by name or by position. |
| Rural Utilities Service Endorsement | WC 00 03 09 B | Assures compliance with RUS guidelines. |
| Sole Proprietors, Partners, Officers and Other Coverage Endorsements | WC 00 03 10 | Extends employees status and benefits to persons normally excluded from coverage (varies by state) |
| Voluntary Compensation and Employers Liability Coverage Endorsement | WC 00 03 11 A | Signifies that an employer has voluntarily chosen to provide workers' compensation coverage and benefits to those not required by state law to be covered. |
| Voluntary Compensation and Employers Liability Coverage for Residence Employees Endorsement | WC 00 03 12A | Same as WC 00 03 11 A except limited to domestic workers. |
| Waiver of our Right to Recover from Others Endorsement | WC 00 03 13 | Waives the insurance carrier's rights of recovery (subrogation and contribution) against the scheduled entity. |
| Workers Compensation and Employers Liability Coverage for Residence Employees Endorsement | WC 00 03 14 A | This endorsement is used when the employer is statutorily required to provide WC to domestic workers (varies by state). The endorsement is designed to be used with homeowners' policies, personal liability policies or similar personal policies. |
| Domestic and Agricultural Workers Exclusion Endorsement | WC 00 03 15 | Used to exclude coverage for domestic and agricultural workers in states where such exclusion is allowed. Applies when the employers employ other workers subject to the law but wants to exclude coverage for domestics and agricultural workers. |
| Labor Contractor Endorsement | WC 00 03 20 A | This endorsement is attached to the leasing employer's policy, extending benefits to the leased employees from the employer's policy. Essentially provides alternate employer status to the scheduled PEO. |
| Professional Employer Organization Extension Endorsement | WC 00 03 20 B | This endorsement extends workers' compensation and employers' liability benefits exclusively from the PEO. Attached to the PEO's policy. This extension only applies to employees leased to the client(s) listed on the schedule. |
| Labor Contractor Exclusion Endorsement | WC 00 03 21 | Attached to the PEO's workers' compensation policy to exclude coverage for employees leased to the client(s) scheduled in the form. This endorsement is used when the client leases employees on an “other-than-short-term" basis and such client is charged with providing the workers' compensation benefits. The Leasing company needs the Labor Contractor Endorsement (WC 00 03 20 A) |
| Employee Leasing Client Exclusion Endorsement | WC 00 03 22 | Attached to the employer's/ client's workers' compensation policy to exclude the extension of workers' compensation benefits to employees leased on a long-term basis from the labor contractor (PEO) scheduled in the policy. Only used when the PEO is responsible for providing coverage. Used when the PEO attaches the WC 00 03 20 B to its policy. |
| Multiple Coordinated Policy Endorsement | WC 00 03 23 | This endorsement extends benefits to the leased employees rather than having to depend on a staffing firm to extend coverage. |
| Residual Market Multiple Company Endorsement | WC 00 03 25 | Attached to employer's policies insured in the residual market with operations in multiple states and the operations in the other states is insured by a separate subsidiary of the insurer. |
| Residual Market Limited Other States Insurance Endorsement | WC 00 03 26A | Extends “Other States" benefits on a limited basis when WC coverage is placed in a residential market. |
| Aircraft Premium Endorsement | WC 00 04 01 A | Indicates the additional premium required under WC code 7421 under passenger seat code 9108. |
| Anniversary Rating Date Endorsement | WC 00 04 02 | Used if the anniversary rating date (related to the experience mod) is different than the policy effective dates. May result from mid-term cancellation and re-write or other cause. |
| Experience Rating Modification Factor Endorsement | WC 00 04 03 | Allows the insurance carrier to change the experience mod mid-term. |
| Pending Rate Change Endorsement | WC 00 04 04 | Allows the insurance carrier to change rates mid-term. |
| Policy Period Endorsement | WC 00 04 05 | Used when the policy period is longer than 1 year and 16 days or does not consist of complete 12-month periods. Might be used to get to a common effective date. |
| Premium Discount Endorsement | WC 00 04 06 A | Shows the calculation for the premium discount. |
| Rate Change Endorsement | WC 00 04 07 | Like the WC 04 04, only the rates have already been approved and will be effective on the specified date. |
| Longshore and Harbor Workers' Compensation Act Rate Change Endorsement | WC 00 04 08 | Like the WC 04 04, only the rates have already been approved and will be effective on the specified date. Applies only to USL&HW coverage. |
| Contingent Experience Rating Modification Factor Endorsement | WC 00 04 12 | A contingent experience modification factor was used to calculate the premium. A new premium calculation will be done once the final mod is calculated. |
| Notification of Change in Ownership Endorsement | WC 00 04 14 | Requires the Insured to report changes in ownership within 90 days (ERM-14). |
| Assigned Risk Adjustment Program Endorsement assigned | WC 00 04 15 A | Attached to insured's in the assigned risk or other such residual programs that are also subject to additional charges (i.e. ARAP charges). |
| Assigned Risk Loss Sensitive Rating Plan Notification Endorsement | WC 00 04 17 A | Notification that an insured in assigned risk plans that reaches a specified premium level may be subject to a retrospective rating plan, regardless of desire. |
| Assigned Risk Mandatory Loss Sensitive Rating Plan Endorsement | WC 00 04 18 C | Like WC 00 04 17 A, except the insured knows up front and this endorsement supplies the rating factors. |
| Premium Due Date Endorsement | WC 00 04 19 | Simply requires the insured to pay when billed. |
| Domestic Terrorism, Earthquakes, and Catastrophic Industrial Accidents Premium Endorsement | WC 00 04 21 C | Notification to the insured that there is additional premium to cover the risk of domestic terrorism or a catastrophic accident. |
| Catastrophe (Other than Certified Acts of Terrorism) Premium Endorsement | WC 00 04 21 D | Notification to the insured that there is additional premium to cover injuries arising from specific catastrophes as defined in the endorsement. |
| Foreign Terrorism Premium Endorsement | WC 00 04 22 A | Allows the insured to charge for and define a foreign terrorist act. |
| Audit Noncompliance Charge Endorsement | WC 00 04 24 | Endorsement allows the insurance carrier to specify the charge if the insured does not comply with premium audit requirements. |
| Experience Rating Modification Factor Revision Endorsement | WC 00 04 25 | See WC 00 04 03 above |
| Retrospective Premium Endorsement One Year Plan | WC 00 05 03 D | Attached to the policy of insured's whose coverage is written on a retrospectively rate (loss sensitive) plan. Endorsement defines the plan and gives the rating factors. |
| Retrospective Premium Endorsement Three Year Plan | WC 00 05 04 D | Like WC 00 05 03 A, except for three-year retro plans. |
| Retrospective Premium Endorsement Long-Term Construction Project | WC 00 05 05 D | Like WC 00 05 03 A, except intended to apply towards long-term construction projects. |
| Retrospective Premium Endorsement Aviation Exclusion | WC 00 05 08 | Used when the aviation exposure is not subject to the retrospective rating plan. |
| Retrospective Premium Endorsement Changes | WC 00 05 09 A | Used when there are changes in the retrospective rating factors or their inapplicability in certain states. |
| Retrospective Premium Endorsement Non-Ratable Catastrophe Element or Surcharge | WC 00 05 10B | Used when a retrospectively rated policy covers a non-ratable catastrophe element or surcharge. Aircraft operations and explosives and ammunition manufacturing classifications are examples. |
| Retrospective Premium Endorsement Short Form | WC 00 05 11 | Used when the insured has more than one retrospectively rated policy subject to the same rating options. |
| Retrospective Premium Endorsement One Year Plan – Multiple Lines | WC 00 05 12 D | Defines retrospective rating, the rating elements and how the premium is calculated. Allows other lines of coverage such as GL and Auto to be included in the calculation of the final premium using the same factors. |
| Retrospective Premium Endorsement Three Year Plan – Multiple Lines | WC 00 05 13 D | Same as WC 00 05 12A, except applies to three-year policies. |
| Retrospective Premium Endorsement Long-Term Construction Project – Multiple Lines | WC 00 05 14 D | Same as WC 00 05 12 A, except applies to long-term construction projects. |
| Retrospective Premium Endorsement Flexibility Options | WC 00 05 15 A | Indicates in which states the incurred losses have been changed to include loss adjustment expenses. |
| Retrospective Rating Plan Premium Endorsement Large Risk Alternative Rating Option (LRARO) | WC 00 05 16 | Allows the WC premium to be calculated retrospectively when written on an alternative rating plan specific for large risks. |
| Benefits Deductible Endorsement | WC 00 06 03 | If the insured operates in a state what allows a WC deductible and to which benefits the deductible apply (medical and indemnity, medical only or indemnity only). |
| Avian Flu Endorsement | Company Specific | Limits the amount of workers' compensation and employers' liability coverage limits to a specified amount for losses arising out of avian flu. |