Assigned Risk: Application & PEO Tips

Helpful tips for completing the ACORD 130, 133 and PEO forms.

Here are some tips on helping you properly complete the required forms to obtain Assigned Risk Workers Compensation Coverage in the State of Indiana.

  • All applications must be submitted electronically via NCCI’s RMAPS Online Application Service. You can access that at and although it does require a log-in and password, there is no fee for using this system.
  • If you absolutely cannot use the NCCI system and must submit a paper application, you will need to complete and mail to us the ACORD 133 Workers Compensation Insurance Plan Assigned Risk section and ACORD 130 Workers Compensation Application.
  • Note: We do not accept walk-in, phone-in or faxed applications.

Checklist “Must Have” Items

Along with the appropriate deposit premium, there are 10 critical pieces of information on the application that you must carefully answer when completing the application and to avoid losing your requested effective date, which may result in a lapse of coverage. These items are:

  • 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.
  • FEDERAL EMPLOYER ID NUMBER: The “EIN” or Employer Identification Number assigned by the Internal Revenue Service ( 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. DO NOT provide a PO Box is this section.
  • 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: The date you are requesting your policy be effective. Based on electronic upload date or postmark date will ultimately decide effective date.
  • RATING INFORMATION: Complete a row for each location by state.
    1. Location: The address where you desire coverage. Also list locations for known or anticipated operations in additional states where you desire coverage.
    2. Class Code: The classification code(s) that best describes the type of business according to Basic Manual rules.
    3. List the number of workers for each class code.
    4. Remuneration: Total annual payroll or other remuneration for each class.
  • INDIVIDUALS INCLUDED/EXCLUDED: The name and title and of each corporate officer, partner, LLC member, or sole proprietor. The percent of ownership, duties, and whether or not each individual will be covered needs to be documented, as well.

Notes: In Indiana, an executive officer of a for-profit corporation is included, but may elect to be excluded. 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 “Notice for Worker’s Compensation and Occupational Diseases Coverage” which is commonly called the sole proprietor or partner election form.

For other employees that you may want to exclude or include, 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 of the company must sign 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 $250,000, please see LSRP rules at bottom of this tips page.

Estimated Annual PremiumPayment BasisMinimum InitialAdditional Payments
Under $2,500Annual100%None
At Least $2,500Semi-Annual75%One
At Least $5,000Quarterly50%Three
At Least $25,000Monthly25%Eight


Indiana law requires that an Employer have three declinations from the voluntary market before they are eligible for coverage in the Assigned Risk market. Along with the application, please upload copies of the declination letters you have received. 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.

Mailing Instructions

If you cannot complete the electronic application through RMAPS and are submitting the paper ACORD forms, these along with the deposit premium check, should be mailed to:​

  • Regular Mail:
    • NCCI—Indiana, Attn: Treasury Dept., PO Box 3045, Boca Raton, FL 33431
  • Overnight Delivery:
    • NCCI—Indiana, Attn: Treasury Dept., 901 Peninsula Corporate Circle, Boca Raton, FL 33487-1362

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 or professional employer organization (PEO). See the definitions below to help you decide. If you are not sure, please call us.

The Basic Manual, Indiana Assigned Risk State Special Rules, 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

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. Leased worker (leased employee) shall mean a person performing services for a client under an employee leasing arrangement.

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 coverage in other states, you will need to 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.

The supplemental employee leasing applications provide the ICRB and Servicing Carriers with additional 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 the new client to the labor contractor’s multiple-coordinated policy (MCP), with the same carrier and expiration date of that of the labor contractor’s policy.

Checklist for a Master Coordinated Policy

Labor Contractor Information

  • Fully completed WCIP application
  • 941 form furnished
  • List of previous names. If none, let us know.
  • List of ownership for labor contractor
  • List of previous owners for last 5 years for labor contractor
  • List of the other labor contractors in which the current owners of the applicant has an ownership interest? If none, let us know.
  • List of combinable entities in which the current ownership of the applicant has an interest? If none, let us know.

Client Information

  • Fully completed WCIP application
  • Client application signed
  • Client 941 form furnished
  • Copy of leasing contract
  • List of other labor contractors providing leased employees to client
  • List of client’s current ownership and list of any ownership changes in last twelve (12) months
  • Complete description of client operations
  • List of leased employees’ names, social security numbers, class codes and wages?
  • Written statement from client indicating current and previous five (5) years carriers and policy numbers
  • Written statement from client listing all previous names the client has operated under in the last five (5) years. If none, let us know.
  • Written statement from client stating non-leased employees that are covered under a current WC policy, carrier name and policy number.
  • List of non-leased employees which includes number of employees and payroll applicable to each code

Checklist for Temporary Agency

If you provide temporary labor services to other employers, in addition to the ACORD forms, you must 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 $250,000.

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.​