Effective 11/01/2014 all company independent applications, forms and endorsements will be converted to follow NCCI number format i.e. WC xx xx xx (xx-xx). As policies renew, forms with revised numbers will be denoted with an * in the Endorsement Schedule indicating *New or revised form.
Some of the more commonly used applications are listed by state below:
Florida
NC3011 Certification of Employer Workplace Safety Program Premium Credit is converting to SAFETY 09-3
Georgia
FM-1483 Georgia Workers Compensation Insurance Benefits Deductible Notice of Election to Accept or Reject is converting to WC 99 06 11
Illinois
FM-934 Notice to Reject Coverage Under Illinois Workers’ Compensation Act is converting to WC 99 06 18
Michigan
FM-402 Certified Resolution is converting to WC 99 06 14 A
FM-403 Application for Exclusion of Officers & Stockholders is converting to WC 99 06 14 B
FM-756 Application for Exclusion From Coverage LLC Member/Manager is converting to WC 99 06 15
FM-1708 Verification of Michigan Workers Compensation Premium Modifications is converting to WC 99 06 07
North Carolina
FM-1281 Notice of Election of Coverage Under Workers’ Compensation Law is converting to WC 99 06 08
FM-1282 Certificate of Exemption From Coverage Under Workers’ Compensation Law is converting to WC 99 06 09
A full listing of forms impacted by this change is attached. If there are questions concerning this, feel free to contact your Underwriter or Field Manager.
WC Forms Renumbered Effective 11/1/2014
|
Form Name (alphabetical): |
Original: |
Converted To: |
|
Application For Exclusion From Coverage LLC Member/Manager |
FM-756 |
WC 99 06 15 |
|
Application For Exclusion Of Officers & Stockholders |
FM-403 |
WC 99 06 14 B |
|
Audit Request Directions |
FM-967 |
WC 99 04 05 |
|
Certificate Of Exemption From Coverage Under Workers’ Compensation Law |
FM-1282 |
WC 99 06 09 |
|
Certification Of Employer Workplace Safety Program Premium Credit |
NC3011 |
SAFETY 09-3 |
|
Certified Resolution |
FM-402 |
WC 99 06 14 A |
|
Dividend Notice |
FM-762 |
WC 99 04 02 |
|
Foreign Coverage Endorsement |
07757 |
WC 99 06 21 |
|
Georgia Amendatory Endorsement |
08840 |
WC 99 03 02 |
|
Georgia Workers Compensation Insurance Benefits Deductible Notice of Election To Accept Or Reject |
FM-1483 |
WC 99 06 11 |
|
Handling Your Workers’ Compensation Claims |
FM-864 |
WC 99 06 16 |
|
Illinois Amendatory Endorsement |
08834 |
WC 99 03 01 |
|
Illinois Medical Benefits Deductible Endorsement |
07758 |
WC 99 03 00 |
|
Independent Contractor Statement |
FM-901 FM-901-ME |
WC 99 06 17 WC 99 06 17 ME |
|
Independent Contractor Statement – Drivers |
FM-1657 |
WC 99 06 13 |
|
Independent Physician Statement |
FM-1470 |
WC 99 06 10 |
|
Keep This Notice With Your Insurance Papers |
FM-603 |
WC 90 06 05 |
|
Membership Information |
05671 05671a |
WC 99 06 01 |
|
Michigan Voluntary Compensation & Employers Liability Coverage Endorsement – Michigan |
85856 |
WC 99 03 05 |
|
Notice Of Election Of Coverage Under Workers’ Compensation Law |
FM-1281 |
WC 99 06 08 |
|
Notice To Policyholders Exemption From State Filing Requirements |
FM-1157 |
WC 90 06 00 |
|
Notice To Reject Coverage Under Illinois Workers’ Compensation Act |
FM-934 |
WC 99 06 18 |
|
Policyholders Notice – Florida (contact number) |
FM-1284 |
WC 90 06 01 |
|
Policyholders Notice – Florida (deductible plan) |
FM-1285 |
WC 90 06 02 |
|
Schedule Modification |
FM-743 |
WC 99 04 03 |
|
Standard Workers’ Compensation And Employer’s Liability Audit Premium |
FM-755 |
WC 99 04 01 |
|
Standard Workers’ Compensation And Employer’s Liability Policy |
84823 93072 |
WC 99 06 00 |
|
Verification Of Michigan Workers Compensation Premium Modifications |
FM-1708 |
WC 99 06 07 |
|
We Are Your Partners In Safety … Loss Control |
FM-1408 |
WC 90 06 03 |
|
Witness Clause |
08826 08826a 10923 |
WC 99 06 05 F
WC 99 06 22 |
|
Workers’ Compensation Audit Request |
FM-966 |
WC 99 04 04 |
|
Workers’ Compensation Claim Handling Procedures |
FM-993 |
WC 99 06 19 |
|
Your Workers’ Compensation Policy Is Subject To Audit |
FM-626-st |
WC 99 04 00 st |
