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Common Workers’ Compensation Forms and Endorsements Descriptions

Author: Chris Boggs

Endorsement NameForm No.Description / Notes
Workers Compensation and Employers Liability PolicyWC 00 00 00 ANCCI policy form
Workers Compensation and Employers Liability Policy Information Page & ExtensionsWC 00 00 01 ADeclaration Page with standard information.
Defense Base Act Coverage EndorsementWC 00 01 01 AExtends 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 EndorsementWC 00 01 02 BExtends WC and EL benefits to employees as per Federal limits and guidelines to employees that contract “Black Lung."
Federal Employers' Liability Act Coverage EndorsementWC 00 01 04 AWorkers' 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 AExtends / 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 EndorsementWC 00 01 08 AExtends 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 EndorsementWC 00 01 09CExtends 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 EndorsementWC 00 01 11Deletes exclusion #12 from the Employers' Liability coverage (Part Two).
Maritime Coverage EndorsementWC 00 02 01 BExtends 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 EndorsementWC 00 02 03WC 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 EndorsementWC 00 03 01 ADesigned 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 EndorsementWC 00 03 02Use to exclude designated workplaces but only when proper and allowable in the law.
Employers' Liability Coverage EndorsementWC 00 03 03 CExtends employers' liability coverage to monopolistic states (ND, Ohio, Wash. And Wyo.).
Insurance Company as Insured EndorsementWC 00 03 04Limits coverage to the insurance carrier's employees only.
Joint Venture as Insured EndorsementWC 00 03 05Limits 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 EndorsementWC 00 03 06Makes the insured solely responsible for paying medical benefits. Used mainly by self-insurers.
Partners, Officers and Other Exclusion EndorsementWC 00 03 08Used 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 EndorsementWC 00 03 09 BAssures compliance with RUS guidelines.
Sole Proprietors, Partners, Officers and Other Coverage EndorsementsWC 00 03 10Extends employees status and benefits to persons normally excluded from coverage (varies by state)
Voluntary Compensation and Employers Liability Coverage EndorsementWC 00 03 11 ASignifies 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 EndorsementWC 00 03 12ASame as WC 00 03 11 A except limited to domestic workers.
Waiver of our Right to Recover from Others EndorsementWC 00 03 13Waives the insurance carrier's rights of recovery (subrogation and contribution) against the scheduled entity.
Workers Compensation and Employers Liability Coverage for Residence Employees EndorsementWC 00 03 14 AThis 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 EndorsementWC 00 03 15Used 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 EndorsementWC 00 03 20 AThis 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 EndorsementWC 00 03 20 BThis 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 EndorsementWC 00 03 21Attached 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 EndorsementWC 00 03 22Attached 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 EndorsementWC 00 03 23This endorsement extends benefits to the leased employees rather than having to depend on a staffing firm to extend coverage.
Residual Market Multiple Company EndorsementWC 00 03 25Attached 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 EndorsementWC 00 03 26AExtends “Other States" benefits on a limited basis when WC coverage is placed in a residential market.
Aircraft Premium EndorsementWC 00 04 01 AIndicates the additional premium required under WC code 7421 under passenger seat code 9108.
Anniversary Rating Date EndorsementWC 00 04 02Used 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 EndorsementWC 00 04 03Allows the insurance carrier to change the experience mod mid-term.
Pending Rate Change EndorsementWC 00 04 04Allows the insurance carrier to change rates mid-term.
Policy Period EndorsementWC 00 04 05Used 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 EndorsementWC 00 04 06 AShows the calculation for the premium discount.
Rate Change EndorsementWC 00 04 07Like 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 EndorsementWC 00 04 08Like 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 EndorsementWC 00 04 12A 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 EndorsementWC 00 04 14Requires the Insured to report changes in ownership within 90 days (ERM-14).
Assigned Risk Adjustment Program Endorsement assignedWC 00 04 15 AAttached 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 EndorsementWC 00 04 17 ANotification 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 EndorsementWC 00 04 18 CLike WC 00 04 17 A, except the insured knows up front and this endorsement supplies the rating factors.
Premium Due Date EndorsementWC 00 04 19Simply requires the insured to pay when billed.
Domestic Terrorism, Earthquakes, and Catastrophic Industrial Accidents Premium EndorsementWC 00 04 21 CNotification 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 EndorsementWC 00 04 21 DNotification to the insured that there is additional premium to cover injuries arising from specific catastrophes as defined in the endorsement.
Foreign Terrorism Premium EndorsementWC 00 04 22 AAllows the insured to charge for and define a foreign terrorist act.
Audit Noncompliance Charge EndorsementWC 00 04 24Endorsement allows the insurance carrier to specify the charge if the insured does not comply with premium audit requirements.
Experience Rating Modification Factor Revision EndorsementWC 00 04 25See WC 00 04 03 above
Retrospective Premium Endorsement One Year PlanWC 00 05 03 DAttached 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 PlanWC 00 05 04 DLike WC 00 05 03 A, except for three-year retro plans.
Retrospective Premium Endorsement Long-Term Construction ProjectWC 00 05 05 DLike WC 00 05 03 A, except intended to apply towards long-term construction projects.
Retrospective Premium Endorsement Aviation Exclusion WC 00 05 08Used when the aviation exposure is not subject to the retrospective rating plan.
Retrospective Premium Endorsement ChangesWC 00 05 09 AUsed when there are changes in the retrospective rating factors or their inapplicability in certain states.
Retrospective Premium Endorsement Non-Ratable Catastrophe Element or SurchargeWC 00 05 10BUsed 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 FormWC 00 05 11Used when the insured has more than one retrospectively rated policy subject to the same rating options.
Retrospective Premium Endorsement One Year Plan – Multiple LinesWC 00 05 12 DDefines 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 LinesWC 00 05 13 DSame as WC 00 05 12A, except applies to three-year policies.
Retrospective Premium Endorsement Long-Term Construction Project – Multiple LinesWC 00 05 14 DSame as WC 00 05 12 A, except applies to long-term construction projects.
Retrospective Premium Endorsement Flexibility OptionsWC 00 05 15 AIndicates 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 16Allows the WC premium to be calculated retrospectively when written on an alternative rating plan specific for large risks.
Benefits Deductible EndorsementWC 00 06 03If 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 EndorsementCompany SpecificLimits the amount of workers' compensation and employers' liability coverage limits to a specified amount for losses arising out of avian flu.

 

Last Updated:  December 6, 2019

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