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To be eligible for coverage in the residual market, an employer must:
For details on the eligibility requirements, refer to NCCI’s
Basic Manual for Workers Compensation and Employers Liability Insurance (Basic Manual) Rule 4-A-3 and
Assigned Risk Supplement—Supplement 3.
Signed Applications (Applicant/Producer Signatures)
The ACORD® 130 and 133 applications must be completed and signed by an owner/officer/partner who is listed in the Individuals Included/Excluded section of the ACORD® 130, as well as the producer/agent, if applicable.
- If the owner/officer/partner has designated a power of attorney (POA) or trustee, a valid copy of the POA or trust document must be submitted with the application
- Incomplete or unsigned application submissions or delays in providing NCCI with additional application information that is requested may hold up the binder or result in the rejection of the application
Required Application Information
- The following critical threshold elements must be included on all applications for coverage under the Workers Compensation Insurance Plan. Refer to NCCI’s
Assigned Risk Supplement—Supplement 4-C.
Critical Threshold Elements|
|Applicant or business name||Complete legal applicant or business name, including doing business as/trading as (DBA/TA) name.|
|Applicant’s mailing address||Address where the policy and other information should be mailed.|
|Applicant’s legal status||Legal structure of applicant (for example, sole proprietor, partnership, corporation, limited liability corporation, joint venture, trust, association, governmental entity).|
|Proposed effective dates and expiration dates||The dates you are requesting coverage.|
Note: An employer can have only one short-term policy (any policy with less than 365 days) in one 12-month period.
|Federal Employer Identification Number (FEIN)||Assigned by the Internal Revenue Service (IRS). The FEIN for each commonly owned and/or managed entity requesting coverage under the application must be provided.|
|Location address(es)||The physical location address or addresses (if more than one location) within the state or states (if more than one state) for which coverage is being requested. These cannot be post office box addresses.|
|State(s) where coverage is requested||The applicant must list each NCCI Plan-administered state in which it has a known and/or anticipated operation and where coverage is desired. Please refer to
NCCI’s Residual Market Limited Other States Insurance Endorsement Guide.|
|Nature of business||The complete detailed description of operations for each location must be included to determine the classification of the business.
For assistance with classifying the business operation, refer to the Classification Table or to
NCCI’s Class Look-Up tool on
- It is the
business of the employer within a state that is classified, not separate employments, occupations, or operations
within the business. Refer to
Basic Manual Rule 1 for classification rules.
- Many class codes can apply to individual industries. Generic terms such as “general contractor,” “construction,” “farm,” or “store” should not be used to describe the operations as this will delay the processing of the application.
|Payroll||Total estimated annual payroll or other appropriate payroll or per capita charges, if applicable, for each class code by location must be provided.
- The payroll for all uninsured contractors for which proof of insurance is not available for the requested policy term must also be included on the application
- Insured subcontractors may be listed on an if-any basis (zero employees, zero payroll) using the class code that best describes their operations
|Officer/owner rating information||To be used in the Individuals Included/Excluded section of the signed applications (i.e., full name and title, description of duties, ownership percentage, class code, estimated annual payroll, and included or excluded). Refer to the
NCCI's Workers Compensation Insurance Plan State Instruction Pages for state requirements and NCCI’s
Basic Manual Rule 2-E.|
|Rating Information||State, location, classification code(s), and payroll are needed for each location within each state listed on the application to ensure that proper total estimated premium is calculated.|
This table will help you classify the business operation. Please refer to the
Assigned Risk Supplement—Supplement 4-C-9-e.
If the applicant is … ||
Describe the …|
|A manufacturer |
- Raw materials used
- Process of work performed
- Products manufactured: who uses them and how they are used
|A contractor (construction)|
- Type of contractor
- Work performed
- Specialized equipment used
- Nature of subcontracts
|A merchant (store) |
- Type of operation: wholesale or retail
- Merchandise sold
- Services provided
- Delivery by the merchant: yes or no
|A service organization |
- Type of service performed
- The applicant’s clients: residential, commercial, or both
|Engaged in agriculture or farming |
Premium Information (Deposit, Premium, Loss Sensitive Rating Plan)
Subject to eligibility under the Workers Compensation Insurance Plan, payment of the deposit premium secures the applicant’s effective date and submits the application to NCCI for review. Refer to
NCCI’s Workers Compensation Insurance Plan State Instruction Pages for state-specific deposit premium requirements.
The Loss Sensitive Rating Plan (LSRP) is a retrospective rating plan for employers whose premium in the assigned risk market is $250,000 or more. If an employer qualifies for LSRP, an LSRP contingency deposit is required. Refer to
Basic Manual Rule 4-C and the Residual Markets section of ncci.com for more information.
The information in this chart is either required by the applicant or producer when submitting an application for coverage.
|Producer email ||X|
|Applicant email ||X||X|
|Agency license number||X|
|Producer license number, state, and expiration date||X|
|Customer service representative name and contact information||X||X|
Submission for Multiple Entities on a Single Application
- The business name, FEIN, location address, and rating information for each entity seeking coverage must be provided
- A completed and signed ERM-14 Form is required to determine the combination of the entities seeking coverage on the same application, if applicable
- Complete and sign the ERM-14 Form using the
Submit Your Experience Rating Ownership Request Online—including electronic signature found on
- Be sure to check the box on the ERM-14 Form that states, “This ownership submission is part of an
RMAPS® Online Application Service.”
Employee Leasing/Professional Employer Organization (PEO) Arrangements
For applications seeking coverage for employee leasing arrangements, the following items must be included on the application:
- Appropriate supplemental
PEO - Assigned Risk Forms found on
- Valid PEO registration information, if required by the state
- Signed copy of the PEO contract for each client obtaining workers compensation insurance
- Complete physical location, nature of business, class code, and payroll for the leased workers
- Signatures of the executive officer, partners, LLC member or manager, as applicable, or owner listed in the Individuals Included/Excluded section of the ACORD® 130 application
Note: States having the same approved PEO rules may be combined on the same application. Refer to the
Professional Employer Organizations (PEO)—Guide to State-Specific Requirements for more information.
Temporary Staffing Arrangement
For applications seeking coverage for temporary staffing arrangements, these items must be included on the application:
- A list of the applicant’s current clients, each client’s address, each client’s nature of business, and the position the temporary employee is filling.
- A copy of the contract the applicant uses with its clients. If contracts are not used, provide copies of the work orders or a statement signed by an owner/officer/partner, stating that all contracts are verbal.
Basic Manual Rule 4.B.1.m for more information on temporary staffing arrangements.
Please call NCCI’s Customer Service Center at 800-NCCI-123 with questions.