Policy Services

Alaska Election of Coverage

• The Alaska Workers' Compensation Act requires each employer having one or more employees in Alaska to obtain workers' compensation insurance, unless the employer has been approved as a self-insurer by the Alaska Workers’ Compensation Board. https://labor.alaska.gov/wc/er-profit.html
• Alaska Workers’ Compensation Law Excludes Sole Proprietors and Partners in a partnership but they may elect coverage through written notice to the carrier. Election is subject to a flat fee and effective the day after receipt by the carrier.
• Alaska Workers’ Compensation Law Excludes Executive officers of for profit corporations who own at least 10% of the corporation and Executive Officers of municipal corporations or charitable, religious, and legally registered non-profit corporations. Officers have the option to elect coverage through written notice to the carrier. Election is subject to a weekly min/max amount based on actual wages and is effective the day after receipt by the carrier. Alaska Workers’ Compensation Law includes officers that own less than 10% of the business entity.
• Alaska Workers’ Compensation Law Excludes Members or Managers of a Limited Liability Company with a minimum of 10% ownership interest. Election is subject to a flat fee and effective the day after receipt by the carrier. Alaska Workers’ Compensation Law Includes Members or Managers of Limited Liability Companies that own less than 10% of the business entity. 

Alaska Inclusion Payroll

• Minimum and Maximum Payroll for Inclusion of Executive Officers
  • 1/1/2024 - $600/$2,400 (Per Week)
  • 1/1/2023 - $600/$2,300 (Per Week)
  • 1/1/2022 - $550/$2200 (Per Week)

• Flat Fee Payroll for Inclusion of Partners, Sole Proprietors and Members or Managers of Limited Liability Companies
  • 1/1/2024 - $39,300 (Annual)
  • 1/1/2023 - $38,800 (Annual)
  • 1/1/2022 - $36,000 (Annual)

Arizona Election of Coverage

AZ WC Law – For details see Arizona Revised Statutes Title 23, Chapter 6 – Workers’ Compensation, Sec: 23-901 to 23-1105

Arizona Workers’ Compensation laws requires employers, with one or more employees, to provide WC coverage for their employees except employers of domestic servants. Employers of domestic servants may elect to provide coverage.

Employee, workman, worker, and/or operative means:

• Every person in the service of this state or a county, city, town, municipal corporation or school district, including regular members of lawfully constituted police and fire departments of cities and towns, whether by election, appointment or contract of hire.
• Every person in the service of any employer subject to this chapter, including aliens and minors legally or illegally allowed to work for hire, but not including a person whose employment is both:
  • Casual
  • Not in the usual course of the trade, business or occupation of the employer
• Lessees of mining property and the lessees’ employees and contractors performing work that is a part of the business conducted, controlled and supervised by the lessor.
• Regular members of volunteer fire departments organized pursuant to title 48, chapter 5, article 1 and title 10, chapters 24 through 40.
• Members of the department of public safety reserve, organized pursuant to section 41-1715
• Any person placed in on-the-job evaluation or training under the department of economic security’s temporary assistance for needy families program or vocations rehabilitation program.
• Regular/certified members of a volunteer sheriff’s reserve.
• Members of the AZ national guard or unorganized militia while receiving military salary.
• Certified ambulance drivers and attendants
• Volunteer personnel who participate in a search or rescue operations and/or training.
• Volunteer personnel who participate in emergency management training, exercises or drills that are duly enrolled or registered with the division of emergency management or any political subdivision.
• Regular members of the AZ game and fish department reserve
• Every person employed pursuant to a professional employer agreement
• LLC members who own less than 50% of membership interest
• A working shareholder of a corporation owning less than 50% of the beneficial interest in the corporation.
• Contract work: When an employer retains supervision or control of work being done by a contractor and the work is a part or process in the trade or business of the employer, then the contractors and the contractor’s employees, and any subcontractor and the subcontractor’s employees are considered employees. See section 23-902 for more information regarding independent contractors.

Sole Proprietorship and Partnership
A sole proprietor or partners of a partnership are not covered by law, but can elect to be included for workers compensation coverage.

Limited Liability Company

1. Working members of a limited liability company who own at least 50% or more of the membership interest in the limited liability company are not covered by law, but can elect to be included for workers compensation coverage.
2. Working members of a limited liability company who own less than 50% of the membership interest in the limited liability company are considered employees and are covered by law.

Corporation

1. Working shareholders of a corporation who own at least 50% or more of the beneficial interest in the corporation are not covered by law, but can elect to be included for workers compensation coverage.
2. Working shareholders of a corporation who own less than 50% of the beneficial interest in the corporation are considered employees and are covered by law.

Arizona Inclusion Payroll

• Minimum and Maximum Payroll for Inclusion of Executive Officers
  • 1/1/2024 - Minimum: $1,250 Per Week; Maximum: $5,000 Per Week (Annual $65,000/$260,000)
  • 1/1/2023 - Minimum: $1,200 Per Week; Maximum: $4,800 Per Week (Annual $62,400/$249,600)
  • 1/1/2022 - Minimum: $1,150 Per Week; Maximum: $4,600 Per Week (Annual $59,800/$239,200)

• Working Sole Proprietors, Partners, Members of a Limited Liability Company, and Shareholders of a Corporation are Subject to the Below Minimum and Maximum Payroll Amounts:
  • 1/1/2024 - Minimum: $600 Per Week; Maximum: $5,393.37 Per Month (Annual $7,200/$64,720)
  • 1/1/2023 - Minimum: $600 Per Month; Maximum: $5,161.12 Per Month (Annual $7,200/$61,933)
  • 1/1/2022 - Minimum: $600 Per Month; Maximum: $5,030.33 Per Month (Annual $7,200/$60,364)

Delaware Election of Coverage

• Any business with one or more employees, including regular part-time workers, must carry workers’ compensation insurance. Farm workers are exempt from the workers’ compensation statute, however, these employers may elect to provide coverage. A household worker in a private home or household who earns less than $750 in cash in any 3-month period from a single private home or household and any person employed as a casual worker in a private home or household who earns less than $750 in cash in any 3-month period from a single private home or household is exempt from coverage. If your business is required to carry the insurance and fails to do so, you’ll be guilty of a misdemeanor. Review insurance requirements with the State Board of Workers’ Compensation. Title 19. Chapter 23 (2374) DE Workers’ Compensation -
  https://delcode.delaware.gov/title19/c023/sc01/index.shtml
• Delaware Workers’ Compensation Law includes executive officers. However, up to 8 executive officers who are stockholders of a corporation or up to 4 members of a limited liability company may be elect to be exempt from this chapter if the corporation and the exempted corporate officers or the limited liability company and the exempted members agree in writing to such an exemption. Anyone or all of the officers who are stockholders of a corporation or anyone or all members of the limited liability company who elect an exemption shall for the purposes of § 2306 of this title be considered employees.
  Note: Construction Corporations or Limited Liability Companies, subject to Title 30 Charter 25 of the Delaware Code, may elect to exclude up to 4 executive officers or up to 4 members of an LLC.As a general rule, executive officers may be excluded only on the effective date of the policy.
• Delaware Workers’ Compensation Law excludes Sole Proprietors and Partners of a partnership, but such sole proprietor or partner may elect coverage in accordance with § 2306 of this title.
• Delaware Workers’ Compensation Law includes members of the immediate family of a sole proprietor or partner however, that any such person may be exempted from this chapter if that person agrees in writing to such an exemption.
• Refer to Delaware Title 19. Chapter 23 ( § 2301) requiring coverage for contractors, subcontractors, independent contractors and lessees of motor vehicles transporting passengers for hire as independent contractors. Independent contractors shall have an option to purchase coverage to satisfy this requirement, or alternatively shall be insured by the general contractor, subcontractor or other contracting entity for which they perform work or provide services. Actual remuneration of the independent contractor will be used to determine premium subject to the executive officer minimum and maximum payrolls approved by the Department of Insurance. Executive officers who are stockholders of a corporation and individuals who are members of a limited liability company may elect to be exempted from the above and this chapter, pursuant to and by complying with § 2308(a) of this title. However, for purposes of this subsection the exemption provided in § 2308(a) of this title for executive officers who are stockholders of a corporation shall be limited to no more than 4 executive officers. Partners and sole proprietors, when working in an independent contractor role, shall be subject to the requirements of this subsection and may not rely upon § 2308(b) and (c) of this title and shall be included for coverage.
• As a general rule, executive officers and individual members of a Limited Liability Company may be excluded only on the effective date of the policy

Delaware Inclusion Payroll

• Minimum and Maximum Payroll for Inclusion of Officers, Sole Proprietors, Partners, or LLC
  • 12/01/2023 - $1,301/$5,200 (Per Week)
  • 12/01/2022 - $1,234/$4,950 (Per Week)
  • 12/01/2021 - $1,197/$4,800 (Per Week)

• Premium for immediate family members of sole proprietors, partners or LLC members shall be based on their actual total payroll

• Any business with three or more workers, including regular part-time workers, must carry workers’ compensation insurance. If your business is required to carry the insurance and fails to do so, you’ll be guilty of a misdemeanor. Review insurance requirements with the State Board of Workers’ Compensation: Title 34. Chapter 9. Workers’ Compensation
• Georgia workers’ compensation law excludes sole proprietors and/or partners, with the option to elect coverage by filing a form WC-10. If a sole proprietor or partner elects coverage, they are considered employees and are included at a flat fee, which is effective the day after receipt by the carrier
• Georgia workers’ compensation law includes members of a Limited Liability Corporation (LLC). Members may elect to exempt themselves from coverage by filing a WC-10 form. The election is effective the day after receipt by carrier.
• Georgia workers’ compensation law includes corporate officers. Officers may elect to exempt themselves from coverage by filing a WC-10 form. The election is effective the day after receipt by carrier.
• https://sbwc.georgia.gov/sites/sbwc.georgia.gov/files/board_forms/wc010.pdf (WC-10 Form)

• Minimum and Maximum Payroll for Inclusion of Officers
  • 3/1/2024 - $1,300/$5,100 (Per Week)
  • 3/1/2023 - $1,200/$4,900 (Per Week)
  • 3/1/2022 - $1,100/$4,600 (Per Week)
• Flat Fee Payroll for Inclusion of Sole Proprietors and Partners
  • 3/1/2024 - $66,800 (Annual)
  • 3/1/2023 - $63,200 (Annual) 
  • 3/1/2022 - $59,700 (Annual)
• Payroll for inclusion of members of an LLC is either treated as an executive officer or as a partner/sole proprietor based on how the LLC is structured to operate for income tax purposes.

Indiana Election of Coverage

• Any business with one or more employees, including regular part-time workers, must carry workers’ compensation insurance. Farm workers and household workers are exempt from the workers’ compensation statute, however, these employers may elect to provide coverage. If your business is required to carry the insurance and fails to do so, you’ll be guilty of a misdemeanor. Review insurance requirements with the State Board of Workers’ Compensation. Title 22. Chapter 23 IN Workers’ Compensation
  http://iga.in.gov/legislative/laws/2020/ic/titles/022#22-3-6-1
• Indiana Workers’ Compensation Law includes executive officers. An executive officer elected or appointed and empowered in accordance with the charter and bylaws of a corporation, other than a municipal corporation or governmental subdivision or a charitable, religious, educational, or other nonprofit corporation, is an employee of the corporation. An officer of a corporation may elect not to be an employee of the corporation under IC 22-3-2 through IC 22-3-6. If an officer makes this election, the officer must serve written notice of the election on the corporation's insurance carrier and the board. An officer of a corporation may elect to be excluded as an employee under IC 22-3-2 through IC 22-3-6 by completing State form 36097 (“Election Form”). Exemption of coverage will not become effective until the notice is received by the insurance carrier and the board.
• Indiana Workers’ Compensation Law excludes Sole Proprietors, Partners, and LLC members/managers but such they may elect coverage in accordance with §22-3-6-1 (b) (4) of this title. An owner of a sole proprietorship, partner in a partnership and LLC member/manager may elect to be included as an employee under IC 22-3-2 through IC 22-3-6 if the owner, partner, or LLC member is actually engaged in the business. If an election is made, the sole proprietor, partner in a partnership and LLC member/manager must serve upon the insurance carrier and upon the board written notice of the election by completing State Form 36097 “Election Form”. No owner of a sole proprietorship, partnership or LLC may be considered an employee under IC 22-3-2 through IC 22-3-6 until the notice has been received.
• Refer to IC 22-3-7-1 for independent contractor coverage and exemption requirements. Indiana Workers’ Compensation Law requires independent contractors (this includes both construction and all other independent contractors) to either maintain coverage or obtain a certificate of exemption under IC 22-3-2-14.5.

Indiana Inclusion Payroll

• Minimum and Maximum Payroll for Inclusion of Officers, Sole Proprietors, Partners, or LLC Members/Managers
  • 1/1/2024 - $950/$4,500 (Per Week)
  • 1/1/2023 - $900/$4,300 (Per Week)
  • 1/1/2022 - $850/$4,000 (Per Week)

Iowa Election of Coverage

Iowa Workers' Compensation Law – For details refer to Iowa Code; Chapters 85, 86 and 87 regarding workers’ compensation, I.C.A. § Sections:  85.1, 85.1A, 85.61 and 87.22

Iowa workers’ compensation laws require employers, with one or more employees, to provide WC coverage for their employees.

Exceptions

• Employers are not required to provide WC coverage for domestic servants receiving less than $1,500 per year.  
• Employers of farm operations are not required to provide WC coverage for family members.

Note: Employers can provide coverage for the above two exceptions by purchasing a workers' compensation policy. 

Sole Proprietors, Partners of a Partnership or Limited Liability Partnership, or Members of Limited Liability Company

Under Iowa Code, a proprietor, limited liability company member, limited liability partner, or partner are not defined as covered employees.  However, the law allows a proprietor, limited liability company member, limited liability partner, or partner to elect to be covered under their workers' compensation and employers' liability policy.

To elect workers’ compensation coverage, they must purchase a valid workers’ compensation insurance policy specifically electing in writing to include themselves.

Officers of a Corporation

Under Iowa Code, officers of a corporation are defined as covered employees.  The law allows up to four corporate officers (president, vice president, secretary, and treasurer) the option to exclude coverage under their workers' compensation and employers' liability policy.

To non-elect workers’ compensation coverage, a corporate officer must provide a written and signed document to exclude coverage for themselves.

Note:  If an owner/officer changes their election of coverage from non-elect to elect, the coverage is not effective until seven days after the written election is received.

Iowa Inclusion Payroll

Minimum and Maximum Payroll for Inclusion of Executive Officers, Members of Limited Liability Companies, Partners, and Sole Proprietors

• 1/1/2024 - Minimum: $550/week; Maximum: $4,400/week (Annual $28,600/$228,800)

Massachusetts Election of Coverage

• All employers operating in the state of Massachusetts are required to carry workers’ compensation insurance for their employees. They are also required to carry coverage on themselves if they are an employee of their company. For more information, please visit the following website: https://www.mass.gov/lists/mass-general-laws-c152
• Massachusetts workers’ compensation law excludes sole proprietors, partners, LLC and/or LLP members. Sole proprietors, partners, LLC and/or LLP members may elect coverage for themselves by sending a written letter signed by the insured on company letterhead, detailing the duties of each sole proprietor, partner, LLC or LLP member who is electing coverage. Election is subject to a flat fee and effective the day after receipt by the carrier.
• Massachusetts workers’ compensation law includes corporate officers. Officers may elect to exempt themselves by filing a Form 153, which must be approved by the Department of Industrial Accidents. The employer must mail a copy of the approved Form 153 to the insurance carrier in order to be exempt. The election is effective the day after receipt by the carrier and subject to officer’s minimum and maximum amounts.
• https://www.mass.gov/service-details/dia-numerical-form-list (Form 153)

Massachusetts Inclusion Payroll

• Minimum and Maximum Payroll for Inclusion of Executive Officers
  • 10/1/2023 - $290/$1,430 (Per Week)
  • 10/1/2022 - $280/$1,410 (Per Week)
  • 7/1/2022 - $270/$1,350 (Per Week)
  • 7/1/2021 - $230/$1,140 (Per Week)
• Flat Fee Payroll for Inclusion of Sole Proprietors, Partners, LLC Members
  • 10/1/2023 - $65,400
  • 10/1/2022 - $64,300
  • 7/1/2022 - $61,700
  • 7/1/2021 - $52,100
• Minimum Payroll Inclusion for Spouses of Individuals, Co-Partners or Corporate Officers
  • 10/1/2023 - $290 (Per Week)
  • 10/1/2022 - $280 (Per Week)
  • 7/1/2022 - $270 (Per Week)
  • 7/1/2021 - $230 (Per Week)

Minnesota Election of Coverage

• Minnesota state law states that all employers are required to purchase workers’ compensation insurance. Please refer to Ch. 176 under the MN State Statute for more information: https://www.revisor.mn.gov/statutes/cite/176
• Minnesota workers’ compensation law excludes sole proprietors, partners, LLC and/or LLP members, and an owners’ parents, spouse, and children, with the option to elect coverage for an owner, and an owners’ parents, spouse, and/or children
• Grandparents, grandchildren, brothers, and sisters are included for coverage and do not have the option to exclude themselves, unless they obtain approval from the Department of Commerce
• Minnesota workers’ compensation law excludes corporate officers of a closely held corporation with less than 22,800 corporate payroll hours and at least 25% ownership, with the option to elect coverage for an owner, and owners’ parents, spouse, and/or children
• Minnesota workers’ compensation law includes corporate officers of a closely held corporation with 22,800 corporate payroll hours or more, and/or less than 25% ownership, or if publicly held. There is no option to exclude coverage for an owner, an owners’ parents, spouse and/or children.

Minnesota Inclusion Payroll

• Minimum and Maximum Payroll for Inclusion for Executive Officers, Partners, Sole Proprietors, and LLC Members
  • 1/1/2024 - $1,337/$5,348 (Per Week)
  • 1/1/2023 - $1,287/$5,148 (Per Week)
  • 1/1/2022 - $1,232/$4,928 (Per Week)
  • 1/1/2021 - $1,144/$4,576 (Per Week)

• Minimum Payroll Inclusion for Spouse, Parent or Child of Individuals, Partners, or Executive Officers of Closely Held Corporations 
  • 1/1/2024 - $401 (Per Week)
  • 1/1/2023 - $386 (Per Week) 
  • 1/1/2022 - $370 (Per Week)
  • 1/1/2021 - $343 (Per Week)

New Jersey Election of Coverage

NJ WC Law – For details see Article 3. Definitions and General Provisions: (34-15-36 Definitions)

New Jersey Workers’ Compensation laws provides coverage for employees including officers of a corporation or unincorporated association, who perform service for an employer for financial considerations, exclusive of:

1. Employees eligible for coverage under the federal Longshore and Harbor WC Act, 44 Stat. 1424 (33 U.S.C.s.901 et seq.)
2. Casual employments defined as the occasion for which arises by chance or is purely accidental, or if not in connection with any business of the employer, as employment not regular, periodic or recurring.

A sole proprietor (self-employed), partners of a limited liability partnership, members of a limited liability company or partners of a partnership are not covered by law, but can elect to be included for workers' compensation coverage.

• The election of coverage must be made prior to the new business or renewal policy effective date and will become effective on the policy effective date.
• The election cannot be made or withdrawn during the policy term.
• If an election is made, coverage applies to all partners or all members. All partners or members must agree to the election. As an example: If there are 3 partners, all three partners must elect to be covered or none are covered.

New Jersey Inclusion Payroll

Executive Officers Defined
Executive Officers are defined as the active, regularly constituted officers of a corporation or unincorporated association and shall include those commonly known and styled as President, Vice President, Secretary or Treasurer.

In order to be considered a “regularly constituted” officer, all three of the following criteria must be met:

Minimum and Maximum Payroll for Inclusion of Executive Officers

• 1/1/2024 - Minimum: $810/week; Maximum: $3,240/week (Annual $42,120/$168,480)
• 1/1/2023 – Minimum: $790/week; Maximum: $3,150/week (Annual $41,080/$163,800)
• 1/1/2022 – Minimum: $760/week; Maximum: $3,050/week (Annual $39,520/$158,600)

Appointed or Elected Public Officers

If the insured is the State, a county, a municipality or any board or commission, or any other governing body, including boards of education and governing bodies of service districts, the payroll of all insured appointed or elected officers shall be included in the statement of payroll and a premium charged thereon, subject to annual minimum payroll amounts.

• For a member of a board of education, the minimum payroll shall be:
  • 1/1/2024 - $8,420/year
  • 1/1/2023 – $8,220/year
  • 1/1/2022 – $7,900/year
• For any other insured appointed or elected officer, the minimum individual payroll shall be:
  • 1/1/2024 - $1,680/year
  • 1/1/2023 – $1,640/year
  • 1/1/2022 – $1,580/year
• If a single individual holds more than one elective or appointive office, the minimum payroll specified above shall apply in connection with each such office.

Sole proprietor (self-employed), partners of a limited liability partnership, members of a limited liability company or partners of a partnership who have elected Coverage are subject to the below minimum and maximum Payroll amounts:

• 1/1/2024 - Minimum: $810/week; Maximum: $3,240/week (Annual $42,120/$168,480)
• 1/1/2023 – Minimum: $790/week; Maximum: $3,150/week (Annual $41,080/$163,800)
• 1/1/2022 – Minimum: $760/week; Maximum: $3,050/week (Annual $39,520/$158,600)

West Virginia Election of Coverage

West Virginia Workers' Compensation Law – For details refer to West Virginia Code § 23-2-1 and § 85-8-6

West Virginia workers’ compensation laws require all employers to provide workers' compensation coverage for their employees, except the following:  

• Employers of Domestic Servants
• Employers of 5 or fewer FT employees in agriculture
• Casual employers, not exceeding 3 employees and employment is temporary, intermittent, and sporadic in nature and does not exceed 10 calendar days
• Churches
• Employers providing coverage under USL&H Act
• Professional sport activities, trainers/Jockeys-horse racing
• Volunteers
• Taxicab drivers who are independent contractors
• Employers with filed exemption of coverage form with the Insurance Commissioner

Note:  Employers can provide coverage for the above two exceptions by purchasing a workers' compensation policy.

Sole Proprietors, Partners of a Partnership or Limited Liability Partnership, Members of Limited Liability Company and Officers of a Corporation or Association

Under the West Virginia Code, a proprietor, limited liability company member, limited liability partner, partner, and officers of a corporation or association are defined as covered employees.  However, the law allows a proprietor, limited liability company member, limited liability partner, partner, and officers to exclude coverage under their workers' compensation and employers' liability policy. 

Exclusion of Coverage

A proprietor, limited liability company member, limited liability partner, partner, or officer of a corporation or association can exclude themselves from workers’ compensation coverage by providing a written exclusion to their workers' compensation carrier prior to the effective date of coverage.

• Up to four officers may exclude themselves from coverage
• Up to four members of a Limited Liability Company may exclude themselves from coverage

West Virginia Inclusion Payroll

Minimum and Maximum Payroll for Inclusion of Executive Officers

• 1/1/2024 - Minimum: $1,000/week; Maximum: $4,000/week (Annual $52,000/$208,000)

Flat Fee Payroll for Inclusion of Partners, Sole Proprietors and Members of Limited Liability Company

• 1/1/2024 - $52,500 (Annual)

Payroll for inclusion of members of an LLC is either treated as an executive officer or as a partner/sole proprietor based on how the LLC is structured to operate for income tax purposes.

Alaska Waiver of Subrogation & Charges

• The Waiver of Our Right to Recover from Others is used when a written contract under which the insured employer’s work is performed, requires that the carrier waive its right of subrogation against a party.
• In order to issue a waiver, carrier requires a copy of the signed contract between all parties, job location, duration of the job, estimated payroll for the job, class code of the employees on the job, and number of employees on the job.
• Specific Waiver Charge: 2% of developed premium in conjunction with the work for which the waiver is provided, for each person or organization named in the endorsement, subject to a $250 annual minimum
• Blanket Waiver Charge: 1.85% of the Total Standard Premium, subject to a $250 minimum annual charge

Additional premium of 5% of manual premium developed in conjunction with the work for which that the waiver is provided, subject to a $250 minimum premium charge per waiver.

5% of manual premium or a minimum of $250

5% of manual premium or a minimum of $250

Indiana Waiver of Subrogation & Charges

• The Waiver of Our Right to Recover from Others is used when a written contract under which the insured employer’s work is performed, requires that the carrier waive its right of subrogation against a party
• In order to issue a waiver, carrier requires a copy of the signed contract between all parties, job location, duration of the job, estimated payroll for the job, class code of the employees on the job, and number of employees on the job
• Waiver fees: In Indiana, the premium charge is 5% of the manual premium developed in conjunction with the work for which the waiver is provided, or a $250 minimum premium for each

Additional premium of 5% of manual premium developed in conjunction with the work for which that the waiver is provided, subject to a $250 minimum premium charge per waiver.

2% of manual premium

5% of manual premium or a minimum of $100

Minnesota Waiver of Subrogation Form

The Waivers of Our Right to Recover From Others endorsement is not approved for use in New Jersey.

Additional premium of 5% of manual premium developed in conjunction with the work for which that the waiver is provided, subject to a $250 minimum premium charge per waiver.

Required for reporting changes in ownership, mergers, consolidations, or combining of entities - https://www.ncci.com/Articles/Pages/UW_ERM14_Form.aspx - AK

https://www.ncci.com/Articles/Pages/UW_ERM14_Form.aspx 

Required for reporting changes in ownership, mergers, consolidations, or combining of entities -
http://www.dcrb.com/shared/d_contents.htm (DE located in “Forms") 

https://www.ncci.com/Articles/Pages/UW_ERM14_Form.aspx

Required for reporting changes in ownership, mergers, consolidations, or combining of entities - https://www.ncci.com/Articles/Pages/UW_ERM14_Form.aspx - IN

https://www.ncci.com/Articles/Pages/UW_ERM14_Form.aspx 

Located under “Applications and Forms” “MA ERM Form- Confidential Request for Information” - https://www.wcribma.org/mass/ToolsandServices/UnderwritingToolsandForms/ApplicationsForms.aspx#ERM

Located at the bottom of the page under “Forms” “Ownership ERM-14” - https://mwcia.org/#

Employers are required to report any entity and/or ownership changes if and when changes occur by completing and submitting the ERM-14 form. The ERM-14 form must be completed for reporting changes in ownership, mergers, consolidations, or combining of entities. The New Jersey Compensation Rating and Inspection Bureau (NJCRIB) requires agents, employers, and members to submit the NJCRIB ERM-14 form online at www.njcrib.com under “Online Services” by selecting the “Ownership” feature. NJCRIB’s website also provides a helpful video about the Manage Ownership platform. Information of any changes should also be sent to our office by email at policyservices@ormarks.com or mail:

Old Republic Residual Market Services
P.O. Box 9325
Minneapolis, MN 55440-9325

https://www.ncci.com/Articles/Pages/UW_ERM14_Form.aspx 

Submit a written request to us with the class code and new payroll by each location. We will increase the premium associated with the increased payroll, and send an endorsement to you and your agency with a new schedule of billing.

Submit a written request to us and provide at least 90 days of the most recent payroll records and/or tax filings to justify the decrease in payroll. Payroll changes less than 60 days from policy expiration date will be determined after the completion of the final audit.

Workers’ Compensation and Employers’ Liability Insurance Policy

Alaska WCIP Assigned Carrier
PMA Ins Co - NCCI Carrier Code 11916

Old Republic Residual Market Services
PO Box 9325 Minneapolis, MN 55440-9325
Website: ormarks.com
Phone: 612-902-9240
Toll Free: 877-347-3596
Fax: 612-902-9241

Policy Dispute Resolution Process

To comply with requirements in state statutes and/or regulations, the Plan Administrator, has established the Workers' Compensation Appeals Board to assist in dispute resolution. The Dispute Resolution Process provides you with a means to resolve disputes regarding your Workers’ Compensation and Employers’ Liability Insurance Policy.

The process has three steps:

1. You must first attempt to resolve the dispute directly with us. To do this, please provide the following information:

• Written notice to us detailing the specific areas of dispute
• An estimate of the premium you believe to be correct, with an explanation of the premium calculation
• Payment of the undisputed portion of the premium

Upon receipt of the written dispute and undisputed premium, we will review all correspondence, policy and loss information, and conduct research of relevant rules and regulations to determine the appropriate resolution. We will provide the resolution in writing including a summary of our decision along with manual rules, regulations, state laws or other pertinent information to support our position and to educate you and/or your agent.

The required information and payment can be sent to us at the above address or documentation can be provided by email at policyservices@ormarks.com.

Every attempt will be made to satisfactorily resolve the dispute by no later than 45 days from receipt of your dispute.

2. If you are not satisfied with our decision and resolution, then you may ask NCCI, the Committee Secretary, for assistance. The Committee Secretary will attempt to assist you and us in reaching a resolution.

After receiving all necessary information regarding the dispute, will Committee Secretary will review the matter and provide a written response within 30 days. Initial requests for dispute resolution services must be sent to NCCI at one of the following:

Mail
NCCI
Dispute Resolution Services
901 Peninsula Corporate Circle
Boca Raton, FL 33487-1362

Email
regulatoryoperations@ncci.com 

Fax
(561) 893-5043

3. If you are still not satisfied with the resolution, then you may ask the Committee Secretary to refer the bona fide dispute to the Advisory Committees’ Workers’ Compensation Grievance Committee.

Attempts to collect premium in dispute or to cancel or non-renew a policy for failure to pay disputed premium will be suspended until the Committee Secretary and/or the Advisory Committees’ Workers’ Compensation Grievance Committee makes a decision on the dispute.

Arizona WCIP Assigned Carrier
PMA Ins Co - NCCI Carrier Code 11916

Old Republic Residual Market Services
PO Box 9325 Minneapolis, MN 55440-9325
Website: ormarks.com
Phone: 612-902-9240
Toll Free: 877-347-3596
Fax: 612-902-9241

Policy Dispute Resolution Process

To comply with requirements in state statutes and/or regulations, the Plan Administrator, has established the Workers' Compensation Appeals Board to assist in dispute resolution. The Dispute Resolution Process provides you with a means to resolve disputes regarding your Workers’ Compensation and Employers’ Liability Insurance Policy.

The process has three steps:

1. You must first attempt to resolve the dispute directly with us. To do this, please provide the following information:

• Written notice to us detailing the specific areas of dispute
• An estimate of the premium you believe to be correct, with an explanation of the premium calculation
• Payment of the undisputed portion of the premium

Upon receipt of the written dispute and undisputed premium, we will review all correspondence, policy and loss information, and conduct research of relevant rules and regulations to determine the appropriate resolution. We will provide the resolution in writing including a summary of our decision along with manual rules, regulations, state laws or other pertinent information to support our position and to educate you and/or your agent.

The required information and payment can be sent to us at the above address or documentation can be provided by email at policyservices@ormarks.com.

Every attempt will be made to satisfactorily resolve the dispute by no later than 45 days from receipt of your dispute.

2. If you are not satisfied with our decision and resolution, then you may ask the Plan Administrator for assistance. The Administrator will attempt to assist you and us in reaching a resolution.

After receiving all necessary information regarding the dispute, the Plan Administrator will review the matter and provide a written response within 30 days. Initial requests for dispute resolution services must be sent to NCCI at one of the following:

Mail
NCCI
Dispute Resolution Services
901 Peninsula Corporate Circle
Boca Raton, FL 33487-1362

Email
regulatoryoperations@ncci.com 

Fax
(561) 893-5043

3. If you are still not satisfied with the resolution, then you may ask the Plan Administrator to refer the bona fide dispute to the board.

Workers’ Compensation and Employers’ Liability Insurance Policy

Delaware WCIP Assigned Carrier:
PMA Ins. Co – NCCI Carrier Code 11916

Old Republic Residual Market Services
PO Box 9325 Minneapolis, MN 55440-9325
Website: ormarks.com
Phone: 612-902-9240
Toll Free: 877-347-3596
Fax: 612-902-9241

Policy Dispute Resolution Process

The Dispute Resolution Process provides you with a means to resolve disputes regarding your Workers’ Compensation and Employers’ Liability Insurance Policy.

The Process has three steps:

1. You must first attempt to resolve the dispute directly with us. To do this, please provide the following information:

• Written notice to us detailing the specific areas of dispute
• An estimate of the premium you believe to be correct, with an explanation of the premium calculation
• Payment of the undisputed portion of the premium.

Upon receipt of the written dispute and undisputed premium, we will review all correspondence, policy and loss information, and conduct research of relevant rules and regulations to determine the appropriate resolution. We will provide the resolution in writing including a summary of our decision along with manual rules, regulations, state laws or other pertinent information to support our position and to educate you and/or your agent.

The required information and payment can be sent to us at the above address, or documentation can be provided by email at policyservices@ormarks.com. 

Every attempt will be made to satisfactorily resolve the dispute by no later than 45 days from receipt of your dispute.

2. If you are not satisfied with our decision and resolution, then you may ask the Administrator for their assistance. After receiving all necessary information regarding the dispute, the Administrator will provide their decision or opinion to assist you and us in reaching a resolution.
Note: DCRB can provide assistance with disputes regarding classifications and experience ratings; it is not their role to become involved in every dispute regarding the allocation of payroll to a given classification. Since the DCRB did not perform the audit, the DCRB does not have the relevant facts on which to base an opinion or render a decision.

Send dispute requests and documentation to DCRB at one of the following:

Mail
Delaware Compensation Rating Bureau, Inc.
30 South 17th Street - Suite 1500
Philadelphia, PA 19103-4007

Website
http://www.dcrb.com/shared/d_contents.htm  (Contacts tab)

Fax
215-564-4328

3. If you are still not satisfied with the resolution, then you may ask the Administrator to refer the bona fide dispute to the Board.

Workers’ Compensation and Employers’ Liability Insurance Policy

Georgia WCIP Assigned Carrier
PMA Ins Co - NCCI Carrier Code 11916

Old Republic Residual Market Services
PO Box 9325 Minneapolis, MN 55440-9325
Website: ormarks.com
Phone: 612-902-9240
Toll Free: 877-347-3596
Fax: 612-902-9241

Policy Dispute Resolution Process

To comply with requirements in state statutes and/or regulations, the NCCI, as Administrator for the Georgia Workers' Compensation Plan, has established the Workers' Compensation Appeals Board to assist in dispute resolution. The board's dispute resolution process provides you with a means to resolve disputes regarding your Workers’ Compensation and Employers’ Liability Insurance Policy. 

The process has three steps:

1. You must first attempt to resolve the dispute directly with us. To do this, please provide the following information:

• Written notice to us detailing the specific areas of dispute
• An estimate of the premium you believe to be correct, with an explanation of the premium calculation
• Payment of the undisputed portion of the premium

Upon receipt of the written dispute and undisputed premium, we will review all correspondence, policy and loss information, and conduct research of relevant rules and regulations to determine the appropriate resolution. We will provide the resolution in writing including a summary of our decision along with manual rules, regulations, state laws or other pertinent information to support our position and to educate you and/or your agent.   

The required information and payment can be sent to us at the above address or documentation can be provided by email at policyservices@ormarks.com.

Every attempt will be made to satisfactorily resolve the dispute by no later than 45 days from receipt of your dispute.

2. If you are not satisfied with our decision and resolution, then you may ask the Administrator for assistance. The Administrator will attempt to assist you and us in reaching a resolution. The Plan Administrator, after receiving all necessary information regarding the dispute, will review the matter and provide a written response within 30 days. Initial requests for dispute resolution services must be sent to NCCI at one of the following:

Mail
NCCI
Dispute Resolution Services
901 Peninsula Corporate Circle
Boca Raton, FL 33487-1362

Email
regulatoryoperations@ncci.com

Fax
(561) 893-5043

3. If you are still not satisfied with the resolution, then you may ask the Administrator to refer the dispute to the Board. Attempts to collect premium in dispute or to cancel or non-renew a policy for failure to pay disputed premium will be suspended until the Georgia Workers' Compensation Appeals Board and/or the Administrator makes a decision on the dispute.

Workers’ Compensation and Employers’ Liability Insurance Policy

Indiana WCIP Assigned Carrier:
PMA Ins Co - NCCI Carrier Code 11916

Old Republic Residual Market Services
PO Box 9325 Minneapolis, MN 55440-9325
Website: ormarks.com
Phone: 612-902-9240
Toll Free: 877-347-3596
Fax: 612-902-9241

Policy Dispute Resolution Process

To comply with requirements in state statutes and/or regulations, the Plan Administrator has established the Workers’ Compensation Appeals Board to assist in dispute resolution. The Dispute Resolution Process provides you with a means to resolve disputes regarding your Workers’ Compensation and Employers’ Liability Insurance Policy.

The Process has three steps:

1. You must first attempt to resolve the dispute directly with us. To do this, please provide the following information:

• Written notice to us detailing the specific areas of dispute
• An estimate of the premium you believe to be correct, with an explanation of the premium calculation
• Payment of the undisputed portion of the premium

Upon receipt of the written dispute and undisputed premium, we will review all correspondence, policy and loss information, and conduct research of relevant rules and regulations to determine the appropriate resolution. We will provide the resolution in writing including a summary of our decision along with manual rules, regulations, state laws or other pertinent information to support our position and to educate you and/or your agent.

The required information and payment can be sent to us at the above address, or documentation can be provided by email at policyservices@ormarks.com.  

Every attempt will be made to satisfactorily resolve the dispute by no later than 45 days from receipt of your dispute.

2. If you are not satisfied with our decision and resolution, then you may ask the Administrator for assistance. The Administrator will attempt to assist you and us in reaching a resolution.

The Plan Administrator, after receiving all necessary information regarding the dispute, will review the matter and provide a written response within 30 days. Initial requests for dispute resolution services must be sent to ICRB at one of the following:

Mail
ICRB
5920 Castleway West Dr., Suite 121
Indianapolis, IN 46250

Email
icrb@icrb.net

Fax
317-842-3717

3. If you are still not satisfied with the resolution, then you may ask the Administrator to refer the bona fide dispute to the Board.

Iowa WCIP Assigned Carrier
PMA Ins Co - NCCI Carrier Code 11916

Old Republic Residual Market Services
PO Box 9325 Minneapolis, MN 55440-9325
Website: ormarks.com 
Phone: 612-902-9240
Toll Free: 877-347-3596
Fax: 612-902-9241

Policy Dispute Resolution Process

To comply with requirements in state statutes and/or regulations, the Plan Administer has established the Workers' Compensation Appeals Board to assist in dispute resolution.  The Dispute Resolution Process provides you with a means to resolve disputes regarding your workers’ compensation and employers’ liability insurance policy.

The process has three steps: 

1. You must first attempt to resolve the dispute directly with us. To do this, please provide the following information:

• Written notice to us detailing the specific areas of dispute.
• An estimate of the premium you believe to be correct, with an explanation of the premium calculation.
• Payment of the undisputed portion of the premium

Upon receipt of the written dispute and undisputed premium, we will review all correspondence, policy and loss information, and conduct research of relevant rules and regulations to determine the appropriate resolution. We will provide the resolution in writing including a summary of our decision along with manual rules, regulations, state laws or other pertinent information to support our position and to educate you and/or your agent.

The required information and payment can be sent to us at the above address or documentation can be provided by email at policyservices@ormarks.com.

Every attempt will be made to satisfactorily resolve the dispute by no later than 45 days from receipt of your dispute.

2. If you are not satisfied with our decision and resolution, then you may ask the Plan Administrator for assistance. The Administrator will attempt to assist you and us in reaching a resolution.

The Plan Administrator, after receiving all necessary information regarding the dispute, will review the matter and provide a written response within 30 days. Initial requests for dispute resolution services must be sent to NCCI at one of the following:

Mail
NCCI
Dispute Resolution Services
901 Peninsula Corporate Circle
Boca Raton, FL 33487-1362

Email
regulatoryassurance@ncci.com 

Fax
(561) 893-5043

3. If you are still not satisfied with the resolution, then you may ask the Administrator to refer the bona fide dispute to the board.

Workers’ Compensation and Employers’ Liability Insurance Policy

MA WC Assigned Risk Pool Assigned Carrier:
PMA Ins Co - NCCI Carrier Code 11916

Old Republic Residual Market Services
PO Box 9325 Minneapolis, MN 55440-9325
Website: ormarks.com
Phone: 612-902-9240
Toll Free: 877-347-3596
Fax: 612-902-9241

Policy Dispute Resolution Process

The dispute resolution process provides you with a means to resolve disputes regarding your Workers’ Compensation and Employers’ Liability Insurance Policy. 

The process has three steps:

• Written notice to us detailing the specific areas of dispute
• An estimate of the premium you believe to be correct, with an explanation of the premium calculation
• Payment of the undisputed portion of the premium

Upon receipt of the written dispute and undisputed premium, we will review all correspondence, policy and loss information, and conduct research of relevant rules and regulations to determine the appropriate resolution. We will provide the resolution in writing including a summary of our decision along with manual rules, regulations, state laws or other pertinent information to support our position and to educate you and/or your agent.   

The required information and payment can be sent to us at the above address or documentation can be provided by email at policyservices@ormarks.com.

Every attempt will be made to satisfactorily resolve the dispute by no later than 45 days from receipt of your dispute or 30 days from receipt of your audit dispute.

2. If you are not satisfied with our decision and resolution, then you may ask The Workers' Compensation Rating & Inspection Bureau of Massachusetts (WCRIBMA), as Administrator for the Massachusetts Workers' Compensation Plan, for assistance and referral to their Appeals Committee. The Administrator and Appeals Committee will attempt to assist all parties in reaching a resolution. All written requests for review with the bureau must be submitted to the following address:

WCRIBMA
Attn: Customer Service Department
101 Arch Street, 5th Floor
Boston, MA 02210

3. If you are still not satisfied with the resolution, you have 30 days from the date of the Appeals Committee’s ruling notice to appeal it in writing with the Commission of Insurance. The request to the Commission should be mailed to:

Commission of Insurance
Division of Insurance
Department of Banking and Insurance
1000 Washing Street, 8th Floor
Boston, MA 02118-2218

Workers’ Compensation and Employers’ Liability Insurance Policy

Carrier Name/Code:
Old Republic Residual Market Services Contract Administrator MN Assigned Risk Plan - 27821

Old Republic Residual Market Services
PO Box 9325 Minneapolis, MN 55440-9325
Website: ormarks.com
Phone: 612-902-9240
Toll Free: 877-347-3596
Fax: 612-902-9241

Policy Dispute Resolution Process

The Dispute Resolution Process provides you with a means to resolve disputes regarding your Workers’ Compensation and Employers’ Liability Insurance Policy.

The process has three steps:

1. You must first attempt to resolve the dispute directly with us. To do this, please provide the following:

• Written notice to us detailing the specific areas of dispute
• An estimate of the premium you believe to be correct, with an explanation of the premium calculation
• Payment of the undisputed portion of the premium

Upon receipt of the written dispute and undisputed premium, we will review all correspondence, policy and loss information, and conduct research of relevant rules and regulations to determine the appropriate resolution. We will provide the resolution in writing including a summary of our decision along with manual rules, regulations, state laws or other pertinent information to support our position and to educate you and/or your agent.   

The required information and payment can be sent to us at the above address or documentation can be provided by email at policyservices@ormarks.com.

Every attempt will be made to satisfactorily resolve the dispute by no later than 45 days from receipt of your dispute.

2. If you are not satisfied with our decision and resolution, then you may ask the Minnesota Workers' Compensation Assigned Risk Plan (MWCARP), as Administrator for the Minnesota Workers' Compensation Plan, for assistance. The Plan Administrator will attempt to assist all parties in reaching a resolution. All written requests for review with the bureau must be submitted to the following address:

MWCARP
ATTN: Sarah Woodward
5600 West 83rd Street
8200 Tower, Suite 1100
Minneapolis, MN 55437
Email: mwcarpadministrator@aon.com 

3. If you are still not satisfied with the resolution, then you may ask the Plan Administrator to refer the dispute to the Minnesota Department of Commerce for a review within 30 calendar days from receipt of the decision notice.

New Jersey WCIP Assigned Carrier
PMA Ins Co - NCCI Carrier Code 11916

Old Republic Residual Market Services
PO Box 9325 Minneapolis, MN 55440-9325
Website: ormarks.com
Phone: 612-902-9240
Toll Free: 877-347-3596
Fax: 612-902-9241

Policy Dispute Resolution Process

To comply with requirements in state statutes and/or regulations, the Plan Administrator, has established the Workers' Compensation Appeals Board to assist in dispute resolution. The Dispute Resolution Process provides you with a means to resolve disputes regarding your Workers’ Compensation and Employers’ Liability Insurance Policy.

The process has three steps:

1. You must first attempt to resolve the dispute directly with us. To do this, please provide the following information:

• Written notice to us detailing the specific areas of dispute
• An estimate of the premium you believe to be correct, with an explanation of the premium calculation
• Payment of the undisputed portion of the premium

Upon receipt of the written dispute and undisputed premium, we will review all correspondence, policy and loss information, and conduct research of relevant rules and regulations to determine the appropriate resolution. We will provide the resolution in writing including a summary of our decision along with manual rules, regulations, state laws or other pertinent information to support our position and to educate you and/or your agent.

The required information and payment can be sent to us at the above address or documentation can be provided by email at policyservices@ormarks.com.

Every attempt will be made to satisfactorily resolve the dispute by no later than 45 days from receipt of your dispute.

2. If you are not satisfied with our decision and resolution, then you may ask the Plan Administrator for assistance. The Administrator will attempt to assist you and us in reaching a resolution.

After receiving all necessary information regarding the dispute, the Plan Administrator will review the matter and provide a written response within 30 days. Initial requests for dispute resolution services must be sent to the Plan Administrator:

Mail
Compensation Rating & Inspection Bureau
60 Park Place
Newark, NJ 07102

Phone
(973) 622-6014

3. In the event an informal conference is unsuccessful in resolving the dispute, further written appeal may be presented to the Rating Bureau’s Executive Director and to the Commissioner of Banking & Insurance.

West Virginia WCIP Assigned Carrier
PMA Ins Co - NCCI Carrier Code 11916

Old Republic Residual Market Services
PO Box 9325 Minneapolis, MN 55440-9325
Website: ormarks.com
Phone: 612-902-9240
Toll Free: 877-347-3596
Fax: 612-902-9241

Policy Dispute Resolution Process

To comply with requirements in state statutes and/or regulations, the Plan Administer has established the Workers Compensation Appeals Board to assist in dispute resolution. The Dispute Resolution Process provides you with a means to resolve disputes regarding your workers’ compensation and employers’ liability insurance policy.

The process has three steps:

1. You must first attempt to resolve the dispute directly with us. To do this, please provide the following information:

• Written notice to us detailing the specific areas of dispute
• An estimate of the premium you believe to be correct, with an explanation of the premium calculation
• Payment of the undisputed portion of the premium

Upon receipt of the written dispute and undisputed premium, we will review all correspondence, policy and loss information, and conduct research of relevant rules and regulations to determine the appropriate resolution. We will provide the resolution in writing including a summary of our decision along with manual rules, regulations, state laws or other pertinent information to support our position and to educate you and/or your agent.  

The required information and payment can be sent to us at the above address or documentation can be provided by email at policyservices@ormarks.com.

Every attempt will be made to satisfactorily resolve the dispute by no later than 45 days from receipt of your dispute.

2. If you are not satisfied with our decision and resolution, then you may ask the Plan Administrator for assistance. The Administrator will attempt to assist you and us in reaching a resolution.

The Plan Administrator, after receiving all necessary information regarding the dispute, will review the matter and provide a written response within 30 days. Initial requests for dispute resolution services must be sent to NCCI at one of the following:

Mail
NCCI
Dispute Resolution Services
901 Peninsula Corporate Circle
Boca Raton, FL 33487-1362

Email
regulatoryassurance@ncci.com 

Fax
(561) 893-5043

3. If you are still not satisfied with the resolution, then you may ask the Administrator to refer the bona fide dispute to the board.