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Assigned
Risk
Application
Tips
| You
can fill it out now or fill it out later. Sending an incomplete
app can VOID your effective date. So, we encourage you
to fill out the whole thing the first time. There are
no shortcuts for assigned risk apps! Here are some tips
to help... |
Online
or Mail
To complete Indiana assigned risk applications, you may
- complete an application online from the NCCI website at
www.ncci.com.
You will be using the RMAPS Online Application Service.
[Exception: PEOs must use mail-in forms only.] You will
need an NCCI ID. To get one, call 800-NCCI-123, or
- complete and mail (not fax) the ACORD 133 Workers Compensation Insurance Plan
Assigned Risk section and ACORD 130 Workers Compensation
Application. To get ACORD Forms, call 1-800-444-3341 or
visit www.acord.com.
- Note: We do not process phone-in or faxed applications.
"Must
Have" Items
Along with the appropriate deposit premium, we require at
least ten things to be completed before we start processing
the application. If you submit an incomplete application,
you could lose your requested effective date, which may result
in a lapse of coverage. We need all remaining information
on the applications as well prior to binding coverage. Here
are the "must have" items:
APPLICANT
NAME: Legal name(s) of the employer.
MAILING
ADDRESS: Where to mail the policy and other information
to the employer.
LEGAL
STATUS: Check the appropriate box or describe the
employer; e.g. sole proprietorship, partnership, limited liability
corporation (LLC), corporation, joint venture, trust, association,
etc. Note: A husband and wife cannot both be a sole proprietor
for one business. Only one of them is the sole proprietor.
Check if perhaps the business is a partnership.
FEDERAL
EMPLOYER ID NUMBER: The "EIN" or Employer Identification
Number assigned by the Internal Revenue Service (www.irs.gov).
A sole proprietor with no employees may provide a social security
number. If a request for an EIN is pending issuance by the
IRS, please provide proof of request.
LOCATIONS:
The physical address where the employer is conducting business.
Also list other locations where you desire coverage. If the
location is a rural route, please also include driving instructions.
If you can't give an address, please explain why.
POLICY
INFORMATION: a. Part 1 - Workers Compensation (States):
List each state in which the employer conducts business and
where you desire coverage. Note: Coverage is only available
in certain states through the National Pool. b. Proposed Effective
Date: Start date for coverage.
RATING
INFORMATION: Needed to calculate total estimated
annual premium. Complete a row for each location by state.
-
Location: The address where you desire coverage. Note: Also
list locations for known or anticipated operations in additional
states where you desire coverage.
-
Class Code: The classification code(s) that best describes
the type of business according to Basic Manual rules.
-
List the number of workers for each class code.
-
Remuneration: Total annual payroll or other remuneration
for each class.
INDIVIDUALS
INCLUDED/EXCLUDED: The name and title of each corporate
officer, partner, LLC member, or sole proprietor. Also, provide
the percent of ownership, duties, and whether or not each
individual will be covered. Notes: In Indiana, an executive
officer of a corporation must be included. An executive officer
of a municipal corporation, other governmental subdivision,
or of a charitable, religious, educational, or other nonprofit
corporation may be covered by specifically including the person
in the insurance policy. A sole proprietor, partner, or LLC
member may elect to be covered. If so, complete the State
Form 36097 (R2/1-88) "Notice for Worker's Compensation and
Occupational Diseases Coverage (79)" which is commonly called
the sole proprietor or partner election form. For other employees
that may be excluded or included, please call us.
NATURE
OF THE BUSINESS/DESCRIPTION OF OPERATIONS: Include
enough detail to ensure proper classification of the business.
For example, operations of a trucker may not be described
simply as "Trucking: NOC," but may be explained as "employer
delivers goods by truck on a contract basis to clients throughout
the midwest."
APPLICANT'S
SIGNATURE: The owner or an officer must sign the
application.
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Deposit
Please make check payable to ICRB. If mailing application, all checks,
including premium financed checks, must be sent with the application.
The chart below will help you
determine the deposit premium. You can find the full set of
rules in the Basic Manual green pages, or the Assigned Risk
Supplement to the Basic Manual.
NOTE: If premium is greater than $100,000, please see LSRP rules
at bottom of this tips page.
Effective
May 1, 2003
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Estimated
Annual
Premium
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Payment
Basis
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Minimum
Initial
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Additional
Payments
|
|
Under
$2,500
|
Annual
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100%
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None
|
|
At
Least $2,500
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Semi-Annual
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75%
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One
|
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At
Least $5,000
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Quarterly
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50%
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Three
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At
Least $25,000
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Monthly
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25%
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Eleven
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Refusers
Indiana law requires three, and one must be the current, voluntary
market carrier. We cannot accept a prior assigned risk carrier.
Effective
Date
The binder and policy effective date is the later of the following
options:
- 12:01
a.m. on date following receipt of a valid application.
- expiration
date of existing coverage, or
- a
date the applicant requests.
Conditions to bind:
The Bureau can only bind coverage after:
-
all application information is complete, and
-
correct deposit premium is deposited in the bank.
Once these conditions are met, the Indiana WCIP rules permit
us to bind coverage the day after the U.S. Postal Service (USPS)
postmark (NO METERED MAIL!). To meet today's business practice
of using overnight delivery service, we also will bind coverage
the day after the courier pick-up date. However, we must have
proof of the pick-up date from the courier. Most overnight envelopes
do not provide sufficient proof so you need to get a log statement
from the courier.
If no postmark or proof of pick-up:
If an envelope has no postmark (remember, metered mail does
not have a postmark!), or the postmark is unreadable, or if
there is no proof of an overnight delivery pick-up date, then
we will bind coverage the day after the bank processes the deposit
check. Under this scenario, the binder date is dependent upon
the days that could pass while the courier is delivering the
envelope and the days that could pass for the bank to open its
mail, enter application header information, and deposit the
check. This could easily reach 5-10 days.
Who is the servicing carrier?
We use several insurance companies to actually write the assigned
risk policies. They are called the servicing carriers. We will
know which carrier is assigned to an employer once the binder
is issued, not before. So, if there is missing information on
the application or the deposit amount is wrong, we cannot bind
coverage and we will not know which servicing carrier will be
picked by our assignment system.
Quick Summary
Do we have...Postmark or Proof of Pick-up?
YES: Bind day after postmark or proof of pick-up.
NO: Bind day after bank deposits check.
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Guide
to Premium
Apply the experience modification, if applicable. Assigned
risk surcharge of 25% applies to the entire premium before
expense constant, when the total modified premium is in excess
of $2,500. Apply TRIA (terrorism) rate of $0.02 and domestic
terrorism rate of $0.01 to all payroll. The servicing carrier
will separately bill the insured for a nominal Indiana Second
Injury Fund surcharge after the policy is issued.
Election/Rejection
Sole proprietors, partners, LLC members, and officers of charitable,
religious, educational or nonprofit corporations are not automatically
covered under Indiana law, but they may elect. For sole proprietors,
partners, and LLC members who are electing coverage, please
attach State Form 36097, Notice For Workers Compensation and
Occupational Diseases Coverage (79). Remember to include their
payroll. Failure to file the appropriate forms for election
or rejection status in acordance with State laws may result
in additional premium being charged and collected by the Plan
Administrator or the assigned carrier.
Corporate
officers, except those mentioned above, must be covered in
the state of Indiana, so their payrolls must be included.
Refer
to the Workers Compensation Board of Indiana for the most
current rules and forms.
Note:
This information applies only to Indiana law. If additional
states are to be covered, additional action may be necessary
under applicable state law.
Mail
to Address
If submitting ACORD forms, please send the application with
deposit to one of these two addresses (we prefer U.S. Postal
Service because of the postmark):
- via
U.S. Postal Service: NCCI-Indiana PO Box 74608 Chicago,
IL 60675-4608
- via
overnight delivery: Lockbox #74608 NCCI, Inc. Northern Trust
Bank 350 N. Orleans St. Receipt and Dispatch 8th Floor Chicago,
IL 60654
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Temporary Service or Employee Leasing?
Before completing applications, first decide if the employer
is involved in a temporary help service or an employee leasing
arrangement (PEO). See the definitions below to help you decide.
If you are not sure, please call us.
The
Basic Manual, Indiana Assigned Risk Special Rules (green pages),
does a good job of defining employee leasing arrangements between
the client (lessee), and the labor contractor (lessor) also
known as the employee leasing company.
RULE
IX. 1. Definitions
a. Employee leasing arrangement shall mean an arrangement,
under contract or otherwise, whereby one business or other
entity leases any or all of its workers from another business.
Employee leasing arrangements include, but are not limited
to, full service employee leasing arrangements, long-term
temporary arrangements, and any other arrangement that involves
the allocation of employment responsibilities among two
or more entities. For purposes of this rule, employee leasing
arrangement does not include arrangements to provide temporary
help service.
b. Temporary help service shall mean a service whereby an
organization hires its own employees and assigns them to clients
for a finite time period to support or supplement the client's
workforce in special work situations such as employee absences,
temporary skill shortages and seasonal workloads.
c.
Client (lessee) shall mean an entity that obtains all or part
of its workforce from another entity through an employee leasing
arrangement or that employs the services of an entity through
an employee leasing arrangement.
d.
Labor contractor (lessor) shall mean an entity that grants
a written lease to a client through an employee leasing arrangement.
In this rule, the labor contractor may also be referred to
as an employee leasing company.
e.
Leased worker (leased employee) shall mean a person performing
services for a client under an employee leasing arrangement.
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Employee Leasing
Assigned risk policies are subject to the "multiple coordinated
policies" rule which basically requires one carrier to issue
a separate policy for each client, all with the same renewal
date, with a master invoice sent to the labor contractor.
The labor contractor will also have its own policy (the master
policy) to cover its direct employees.
Note: Because each state can have different requirements (registration
and licensing) for employee leasing arrangements, the ICRB only
processes applications for the Indiana portion of a multi-state
labor contractor or PEO. For other states, contact NCCI.
Employers involved in employee leasing arrangements will need
to complete additional information to tell us about the arrangement
so that the proper coverage can be established by the servicing
carrier. Answers to the following questions on the ACORD forms
will indicate what additional information and forms are needed.
Question
#6 - Do you lease workers from a labor contractor? If you
answered yes, please complete the Client
Supplemental Employee Leasing Application.
Question
#7 - Do you lease workers to client companies?
Question #8 - Are you seeking to cover the leased workers?
If you answered yes to Question #7 and to Question #8, please
complete the Labor Contractor
Supplemental Employee Application side A and side B for
each client.
If
you answered yes to Question #7 and not to Question #8, please
complete the Labor Contractor
Supplemental Employee Application side A.
The supplemental employee leasing applications provide us
and the carriers with more underwriting information than what
we can get by just using the ACORD 130 & 133 forms. Every
time the labor contractor gets a new client, we will need
an application (with the supplemental applications) for that
client. This process allows us to assign a new client to the
labor contractor's multiple-coordinated policy (MCP).
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Checklist
for a Master Coordinated Policy
A.
Labor Contractor Information
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Fully completed WCIP application?
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941 form furnished?
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Listing of previous names? If none, let us know.
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Listing of ownership for labor contractor?
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Listing of previous owners for last 5 years for labor
contractor?
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Listing of the other labor contractors in which the current
owners of the applicant has an ownership interest? If
none, let us know. Interest in another labor contractor?
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Listing of combinable entities in which the current ownership
of the applicant has an interest? If none, let us know.
B.
Client Information
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Fully completed WCIP application?
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Client application signed?
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Client 941 form furnished?
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Copy of leasing contract?
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Listing of other labor contractors providing leased employees
to client?
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Listing of client's current ownership and listing of any
ownership changes in last twelve (12) months?
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Complete description of client operation?
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Listing of leased employees names, social security numbers,
class codes and wages?
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Written statement from client indicating current and previous
five (5) years carriers and policy numbers?
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Written statement from client listing all previous names
the client has operated under in the last five (5) years?
If none, let us know.
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Written statement from client stating non-leased employees
are covered under a current WC policy with carrier and
policy number.
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Listing of non-leased employees which includes number
of employees and payroll applicable to each code?
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Checklist
for Temporary Agency
Question
#6 - on ACORD 133 Form "Do you provide temporary labor
services to other employers?" If you answered yes, please
complete the Temporary Employment
Contractor Information form.
Loss
Sensitive Rating Plan
The Loss Sensitive Rating Plan (LSRP) is a mandatory assigned
risk retrospective rating program for employers whose standard
premium is equal to or exceeds $100,000 (reduced from $200,000
for new and renewal policies effective 12/01/2002).
In addition to the normal deposit premium, we require an additional
LSRP contingency deposit premium of 20% of standard premium,
or an acceptable, clean, unconditional irrevocable Letter
of Credit (ILOC) containing the automatic renewal clause.
All ILOC's must be drawn on a bank that is a member of the
Federal Reserve.
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