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(New)Denotes change.PAGE WC 1 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
Workers' CompensationPolicy Forms and Endorsements
ALPHABETICAL INDEX
Forms are listed alphabetically by form title.
The forms included in this section, which WOLTERS KLUWER makes available as stock items, are as follows:
1. Standard and Advisory ‘‘General Use’’ and ‘‘State’’ Endorsements based on National Council on Compensation Insurance (NCCI) text.2. Endorsements containing ‘‘Tables of Rating Values’’ (used in conjunction with ‘‘Retrospective Premium Endorsements’’). Based on NCCI text.3. Specific state endorsements in text provided by local Workers Compensation Boards or Bureaus with corresponding Identification Numbers when
designated.
Monopolistic Jurisdiction: None of the forms listed herein are for use in the following jurisdictions having a "monopolistic" Workers' Compensation program,except where specifically listed: Ohio, North Dakota, Washington, and Wyoming. Certain Employers Liability forms may, of course, be used even though Workers'Compensation is not used.
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
--------------------------------------------------------GENERAL USE/STATE SPECIFIC
--------------------------------------------------------Alabama
WC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC598 11/96 WC010402 ANNIVERSARY RATING DATE
ENDORSEMENTWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM
ENDORSEMENTWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING
PLAN ENDORSEMENTWC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATING
PLAN NOTIFICATION ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC463 11/92 WC 01 04 01 MERIT RATING ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
AlaskaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC540601 01/13 WC5406010113 ALASKA NOTICE OF INSTALLMENT
OPTION ENDORSEMENTFORM542 03/13 FORM 54-2 ALASKA POLICYHOLDER NOTICE -
ACCESS TO MANUAL INFORMATIONWC540403 01/99 WC5404030199 ALASKA RESIDUAL MARKET SAFE
WORKPLACE INCENTIVEWC540501 B 01/19 WC540501B ALASKA RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC540504 B 01/19 WC540504B ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC540502 B 01/19 WC540502B ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC540505 01/15 WC540505A ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC540505 B 01/19 WC540505B ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC540503 B 01/19 WC540503B ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC540506 B 01/19 WC540506B ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC465 09/92 WC 54 04 01 ASSIGNED RISK PREMIUM SURCHARGEWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC573 05/95 WC540602 CANCELLATION AND NONRENEWAL
ENDORSEMENTWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC584 01/96 WC540402 CONTRACTING CLASSIFICATION
PREMIUM ADJUSTMENT ENDORSEMENTWC646 12/03 FORM541CCPAP CONTRACTING CLASSIFICATION
PREMIUM ADJUSTMENT PROGRAMWORKERS COMPENSATION PREMIUMCREDIT APPLICATION
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUMENDORSEMENT
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC572 05/95 WC540301 LIMIT OF LIABILITY ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 6 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
ArizonaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC020401 C 02/10 WC 02 04 01 C ALCOHOL/DRUG-FREE WORKPLACE
PREMIUM CREDIT ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC020602 08/02 WC 02 06 02 ARIZONA BENEFITS DEDUCTIBLE
ENDORSEMENTWC020601 A 09/15 WC 02 06 01 A ARIZONA CANCELLATION AND
NONRENEWAL ENDORSEMENTWC020301 A 05/17 WC 02 03 01 A ARIZONA EMPLOYEE LEASING
ENDORSEMENTWC020501 03/02 WC 02 05 01 ARIZONA RETROSPECTIVE PREMIUM
ENDORSEMENT LARGE RISKALTERNATIVE RATING OPTION
WC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT
WC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGEENDORSEMENT
WC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGEENDORSEMENT
WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC330 05/86 WC 02 06 01 CANCELLATION ENDORSEMENT
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC604 01/97 WC0203020197 EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC603 01/97 WC0203010197 EMPLOYEE LEASING ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC605 01/97 WC0203030197 LABOR CONTRACTOR EXCLUSION
ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 8 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGEENDORSEMENT
WC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
ArkansasWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC262 A 04/92 WC 03 06 01 A AMENDATORY ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC030601 B 03/18 WC 03 06 01 B ARKANSAS AMENDATORY
ENDORSEMENTWC030603 B 07/19 WC 03 06 03 B ARKANSAS CONTRACT HAULING
WARRANTY ENDORSEMENTWC030402 A 01/18 WC 03 04 02 A ARKANSAS TABULAR ADJUSTMENT
PROGRAM ENDORSEMENTWC552 01/94 WC030301 ASSIGNED RISK ASSOCIATED OR
SPONSORED POLICY COVERAGEENDORSEMENT
WC553 01/94 WC030302 ASSIGNED RISK MULTIPLECOORDINATED POLICY COVERAGEENDORSEMENT
WC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT
WC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGEENDORSEMENT
WC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGEENDORSEMENT
WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC556 A 10/96 WC030602A1096 BENEFITS DEDUCTIBLE ENDORSEMENT
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 10 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC617 10/97 WC0304041097 MANAGED CARE ENDORSEMENTWC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSION
ENDORSEMENTWC118 04/84 WC 00 03 07 MEDICAL BENEFITS REIMBURSEMENT
ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC000414 A 01/19 WC 00 04 14 A
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 11 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 12 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
WC540 03/94 WC030401 WORKERS COMPENSATION INSURANCEPLAN ALTERNATE PREFERRED PLANPREMIUM ENDORSEMENT
WC539 03/94 WC030403 WORKERS COMPENSATION INSURANCEPLAN MERIT RATING ENDORSEMENT
CaliforniaWC040412 11/02 WC0404121102 1999 PREMIUM INCREASE
ENDORSEMENT - CALIFORNIAWC040413 11/02 WC0404131102 2000 PREMIUM INCREASE
ENDORSEMENT - CALIFORNIAWC040414 11/02 WC0404141102 2001 PREMIUM INCREASE
ENDORSEMENT - CALIFORNIAWC040415 11/02 WC0404151102 2002 PREMIUM INCREASE
ENDORSEMENT - CALIFORNIAWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC040399 04/16 WC040399 CALIFORNIA CUSTOMIZED LIMITING
AND RESTRICTING ENDORSEMENTAGREEMENT - ENDORSEMENTAGREEMENT LIMITING ANDRESTRICTING THIS INSURANCE
WC040422 01/12 WC040422 CALIFORNIA SHORT-RATECANCELATION ENDORSEMENT
WC535 12/93 WC040601A CANCELLATION ENDORSEMENT(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIED
ACTS OF TERRORISM) PREMIUMENDORSEMENT
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC565 01/95 WC0403100195 DUTY TO DEFENDWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC387 A 10/98 WC040307A1098 EMPLOYEE LEASING ENDORSEMENTWC626 A 10/98 WC040312A1098 EMPLOYEE LEASING ENDORSEMENT
(FOR LEASING ARRANGEMENTS THATDO NOT FALL WITHIN THE SCOPE OFTHE EMPLOYEE)
WC388 A 10/98 WC040308A1098 EMPLOYEE LEASING ENDORSEMENTSHORT FORM
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 13 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC625 A 10/98 WC040311A1098 EMPLOYEE LEASING ENDORSEMENTSHORT FORM (FOR LEASINGARRANGEMENTS THAT DO NOT FALLWITHIN THE SCOPE OF THE EMPLOYEELEASING RULE)
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC040360 B 01/15 WC040360B EMPLOYERS’ LIABILITY COVERAGEAMENDATORY ENDORSEMENT -CALIFORNIA
WC040345 A 10/16 WC040345A ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -COMPREHENSIVE PERSONAL LIABILITYPOLICY EXCLUSION
WC040338 B 02/18 WC 04 03 38 B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -DESIGNATED EMPLOYEE(S) EXCLUSION
WC040340 B 02/18 WC 04 03 40 B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -DESIGNATED LOCATION(S) COVERAGE
WC040341 B 02/18 WC 04 03 41 B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -DESIGNATED LOCATION(S) EXCLUSION
WC040344 B 02/18 WC 04 03 44 B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE- DESIGNATED OPERATION(S) ATDESIGNATED LOCATION(S) COVERAGE
WC040343 B 02/18 WC 04 03 43 B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE- DESIGNATED OPERATION(S) ATDESIGNATED LOCATION(S) EXCLUSION
WC040339 B 02/18 WC 04 03 39 B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -DESIGNATED OPERATION(S) COVERAGE
WC040342 B 02/18 WC 04 03 42 B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -DESIGNATED OPERATION(S) EXCLUSION
WC040350 04/16 WC040350 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE- INSURANCE COMPANY AS INSUREDEXCLUSION
WC040337 A 04/16 WC040337A ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -JOINT VENTURE EXCLUSION
WC040336 A 04/16 WC040336A ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE- JOINTLY CONDUCTED OPERATIONSEXCLUSION
WC040332 04/16 WC040332 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -MEDICAL BENEFITS EXCLUSION
WC040303 C 07/18 WC 04 03 03 C ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -OFFICERS AND DIRECTORS COVERAGE /EXCLUSION - CALIFORNIA
WC040302 D 07/18 WC 04 03 02 D ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -PARTNERSHIP COVERAGE / EXCLUSION -CALIFORNIA
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 14 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC040333 04/16 WC040333 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE- PARTNERSHIP COVERAGE / JOINTLYAND NOT SEVERALLY EXCLUSION
WC040366 07/18 WC 04 03 66 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE- PROFESSIONAL CORPORATIONCOVERAGE / EXCLUSION CALIFORNIA
WC040331 A 04/16 WC040331A ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -RESIDING RELATIVES EXCLUSION
WC040317 B 10/16 WC040317B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(EMPLOYEE INSURED BY GENERALEMPLOYER EXCLUDED)
WC040313 B 10/16 WC040313B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(LABOR CONTRACTOR AS NAMEDINSURED - EXCLUSION OF LEASEDEMPLOYEES)
WC040315 B 10/16 WC040315B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(LABOR CONTRACTOR AS NAMEDINSURED WITH LCF DESIGNATION—RESTRICTION OF COVERAGE TO CLIENTWORKERS)
WC040316 B 10/16 WC040316B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(LABOR CONTRACTOR AS NAMEDINSURED—EXCLUSION OF CLIENT'SEMPLOYEES)
WC040314 B 10/16 WC040314B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(LABOR CONTRACTOR AS NAMEDINSURED—RESTRICTION OF COVERAGETO CLIENT WORKERS)
WC7765 05/94 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE/WORKERS’ COMPENSATION ANDEMPLOYERS’ LIABILITY POLICYAMENDATORY ENDORSEMENT
WC040410 A 01/18 WC 04 04 10 A ESTIMATED ANNUAL PREMIUMENDORSEMENT—CALIFORNIA
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC040005 07/98 WC0400050798 EXTENSION OF INFORMATION PAGE—CLASSIFICATIONS
WC040004 07/98 WC0400040798 EXTENSION OF INFORMATION PAGE—SCHEDULE OF FORMS
WC040003 07/98 WC0400030798 EXTENSION OF INFORMATION PAGE—SCHEDULE OF LOCATIONS
WC040002 07/98 WC0400020798 EXTENSION OF INFORMATION PAGE—SCHEDULE OF NAMED INSURED
WC040406 G 01/20 WC 04 04 06 G FARM SCHEDULE ENDORSEMENT -CALIFORNIA
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC040001 B 10/14 WC040001B INFORMATION PAGEWC040411 01/04 WC0404110104(CA)
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 15 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
INSOLVENT RATING ADJUSTMENT PLANENDORSEMENT
WC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSUREDENDORSEMENT
PN049907 A 07/15 PN049907A JANUARY 1, 2014 AUDIT REQUIREMENTSFOR POLICIES WITH FINAL PREMIUMOF LESS THAN $10,000 THAT DEVELOPPAYROLL IN HIGH WAGE DUALWAGE CONSTRUCTION OR ERECTIONCLASSIFICATIONS
WC116 04/84 WC 00 03 05 JOINT VENTURE AS INSUREDENDORSEMENT
WC040603 B 01/15 WC040603B LARGE RISK DEDUCTIBLEENDORSEMENT
WC040318 C 07/18 WC 04 03 18 C LIMITED LIABILITY COMPANYCOVERAGE / EXCLUSIONENDORSEMENT-CALIFORNIA
WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGEENDORSEMENT
WC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT
WC247 A 04/92 WC040101A0492 LONGSHOREMEN’S AND HARBORWORKERS COMPENSATION ACTCOVERAGE ENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
PN049903 11/99 PN0499031199 NOTICE REQUIRED BY LAWWC040421 01/08 WC0404210108 OPTIONAL PREMIUM INCREASE
ENDORSEMENT - CAWC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDS
ACT COVERAGE ENDORSEMENTWC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITY
INSURANCEWC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERS
EXCLUSION ENDORSEMENTWC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC166 B 03/98 WC 04 03 01A POLICY AMENDATORY ENDWC040301 D 02/18 WC040301C POLICY AMENDATORY ENDORSEMENT -
CALIFORNIAPN049904 12/01 PN0499041201 POLICY HOLDER NOTICE - CALIFORNIA
INSURANCE GUARANTEE ASSOCIATION(CIGA) SURCHARGE
WC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTPN049908 12/19 PN049908 POLICYHOLDER NOTICE - CALIFORNIA
ASSEMBLY BILL NO 5., INDEPENDENTCONTRACTORS
PN049906 D 01/20 PN 04 99 06 D POLICYHOLDER NOTICE - PAYROLLRECORD AND AUDIT REQUIREMENTSFOR DUAL WAGE CONSTRUCTION ORERECTION CLASSIFICATIONS
PN049902 B 05/02 PN049902B0502
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
POLICYHOLDER NOTICE (INSURANCERATING LAWS)
PN049901 G 03/19 PN 04 99 01 G POLICYHOLDER NOTICE (YOURRIGHT TO RATING AND DIVIDENDINFORMATION)
WC040407 10/99 WC0404071099 PREMIUM ADJUSTMENT ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC040401 A 01/18 WC 04 04 01 A RATING EFFECTIVE DATE
ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC561 01/95 WC0405110195 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC040501 E 01/15 WC040501E RETROSPECTIVE PREM END [CA]WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC040602 B 12/06 WC040602B1206 SMALL DEDUCTIBLE ENDORSEMENTWC250 A 01/85 WC040304 SOLE PROPRIETOR COVERAGE
ENDORSEMENT(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAM
REAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC251 A 01/85 WC040305 VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC122 B 08/91 WC 00 03 11 B
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 17 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC252 04/84 WC040306 WAIVER OF OUR RIGHT TO RECOVERFROM OTHERS ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
ColoradoWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC385 11/90 WC 05 04 02 CLASSIFICATION ENDORSEMENTWC050404 A 01/12 WC 05 04 04 A COLORADO NON-COOPERATION
WITH PREMIUM AUDIT SURCHARGEENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUMENDORSEMENT
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION
ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGEENDORSEMENT
WC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC567 03/93 WC050403 PREMIUM CREDIT FOR CERTIFIED
RISK MANAGEMENT PROGRAMSENDORSEMENT
WC266 07/91 WC 00 04 09 PREMIUM DETERMINATIONENDORSEMENT - FORMER SELF-INSURERS 1
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 19 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
ConnecticutWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC199 04/84 WC 06 03 01 APPLICATION OF WORKERS
COMPENSATION INSURANCEENDORSEMENT
WC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAMENDORSEMENT
WC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATINGPLAN ENDORSEMENT
WC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATINGPLAN NOTIFICATION ENDORSEMENT
WC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT
WC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGEENDORSEMENT
WC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGEENDORSEMENT
WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIED
ACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC060402 01/14 WC 06 04 03 CONNECTICUT FOREIGN VOLUNTARYCOMPENSATION AND EMPLOYERSLIABILITY COVERAGE ENDORSEMENT
WC060601 A 10/17 WC 06 06 01 A CONNECTICUT WORKERS'COMPENSATION FUNDS
WC362 01/90 WC 00 04 12
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 20 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC588 07/96 WC060401 CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT ENDORSEMENT
NC5000 D 08/19 NC-5000 D CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT PROGRAMWORKERS COMPENSATION PREMIUMCREDIT APPLICATION
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC392 04/91 WC 00 03 20 LABOR CONTRACTOR ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC060602 07/08 WC 06 06 02 MANDATORY ARBITRATIONENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 21 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC890600 B 07/01 WC890600B POLICY INFORMATION PAGEENDORSEMENT
WC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC267 07/91 WC 00 04 10 PREMIUM DETERMINATIONENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC146 04/84 WC 06 05 01 RETRO PREM SUPP (CT)WC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 22 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
DelawareFORM07-1 10/04 FORM0711004 AGREEMENT BY EXECUTIVE OFFICE
NOTICEFORMDCRB-EX
12/09 DCRB-EXCL AGREEMENT BY EXECUTIVE OFFICER(S)/LLC MEMBER(S) NOT TO BE SUBJECTTO THE DELAWARE WORKERS'COMPENSATION LAW
WC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC184 04/84 WC 07 03 03 AMENDATORY ENDORSEMENT—
FARMING OPERATIONSWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC375 07/90 WC 07 04 02 CONSTRUCTION CLASSIFICATION
PREMIUM ADJUSTMENT ENDORSEMENTWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC181 04/84 WC 07 04 01 DEDUCTIBLE ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC651 J 07/19 DCCPAP DELAWARE WORKERS COMPENSATION
PREMIUM CREDIT APPLICATIONWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUMENDORSEMENT
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 23 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
LIMITED MARITIME COVERAGEENDORSEMENT
WC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSION
ENDORSEMENTWC118 04/84 WC 00 03 07 MEDICAL BENEFITS REIMBURSEMENT
ENDORSEMENTWC070408 07/99 WC 07 04 08 MERIT RATING PLAN ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC358 07/88 WC 07 06 01 NONRENEWAL ENDORSEMENTWC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENT
OF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC481 10/93 WC 00 05 15 RETROSPECTIVE PREMIUM
ENDORSEMENT - FLEXIBILITY OPTIONSWC414 12/91 WC 00 05 05 A
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 24 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RETROSPECTIVE PREMIUMENDORSEMENT - LONG TERMCONSTRUCTION PROJECT
WC417 12/91 WC 00 05 14 A RETROSPECTIVE PREMIUMENDORSEMENT - LONG-TERMCONSTRUCTION PROJECT - MULTIPLELINES
WC144 04/84 WC 00 05 10 RETROSPECTIVE PREMIUMENDORSEMENT - NON-RATABLECATASTROPHE ELEMENT ORSURCHARGE
WC412 12/91 WC 00 05 03 A RETROSPECTIVE PREMIUMENDORSEMENT - ONE YEAR PLAN
WC415 12/91 WC 00 05 12 A RETROSPECTIVE PREMIUMENDORSEMENT - ONE YEAR PLAN -MULTIPLE LINES
WC413 12/91 WC 00 05 04 A RETROSPECTIVE PREMIUMENDORSEMENT - THREE YEAR PLAN
WC416 12/91 WC 00 05 13 A RETROSPECTIVE PREMIUMENDORSEMENT - THREE YEAR PLAN -MULTIPLE LINES
WC650 04/84 WC000509 RETROSPECTIVE PREMIUMENDORSEMENT CHANGES
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC120 04/84 WC 00 03 09 RURAL ELECTRIFICATIONADMINISTRATION ENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
District of ColumbiaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 25 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
ASSIGNED RISK ADJUSTMENT PROGRAMENDORSEMENT
WC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATINGPLAN ENDORSEMENT
WC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATINGPLAN NOTIFICATION ENDORSEMENT
WC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT
WC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGEENDORSEMENT
WC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGEENDORSEMENT
WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC263 04/84 WC 08 06 01 CANCELLATION ENDORSEMENT
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC392 04/91 WC 00 03 20 LABOR CONTRACTOR ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSION
ENDORSEMENTWC118 04/84 WC 00 03 07 MEDICAL BENEFITS REIMBURSEMENT
ENDORSEMENTWC448 07/92 WC 00 01 11
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 26 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
MIGRANT AND SEASONALAGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UP
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 27 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
CONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC080401 B 01/18 WC 08 04 01 B SAFE WORKPLACE PROGRAMENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
FloridaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEFORM0901 A 11/19 FORM09-01A APPLICATION FOR DRUG-FREE
WORKPLACE PREMIUM CREDITPROGRAM
WC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT
WC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGEENDORSEMENT
WC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGEENDORSEMENT
WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC401 07/90 WC 09 06 05 BENEFITS DEDUCTIBLE ENDORSEMENTNC3011 07/06 FORMSAFETY93 CERTIFICATION EMPLOYER
WORKPLACE SAFETY PROGRAMPREMIUM CREDIT
FORM09-3 11/19 SAFETY 09-3A CERTIFICATION OF EMPLOYERWORKPLACE SAFETY PROGRAMPREMIUM CREDIT
WC399 07/90 WC 09 06 03 COINSURANCE AND DEDUCTIBLEENDORSEMENT
WC400 07/90 WC 09 06 04 COINSURANCE ENDORSEMENTERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR
OWNERSHIP INFORMATIONWC060603 03/19 WC 06 06 03 CONNECTICUT NOTICE OF
CANCELLATION OR MATERIALCOVERAGE CHANGE TO DESIGNATEDGOVERNMENTAL ENTITYENDORSEMENT
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
FORM094 E 11/19 FORM 09-4E CONTRACTING CLASS PREM ADJ(FL)WC483 06/87 WC 09 04 01 CONTRACTING CLASSIFICATION
PREMIUM ADJUSTMENT ENDORSEMENTWC217 04/92 WC 00 01 01 A
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 28 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC090303 08/05 WC 09 03 03 EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC090314 07/07 WC 09 03 14 FLORIDA EMPLOYEE LEASINGCOMPANY CLIENT COMPANY DIRECTWORKERS INCLUSION ENDORSEMENT
WC090311 07/07 WC 09 03 11 FLORIDA EMPLOYEE LEASINGCOMPANY CLIENT COMPANYEXCLUSION ENDORSEMENT
WC090312 07/07 WC 09 03 12 FLORIDA EMPLOYEE LEASINGCOMPANY EXCLUSION ENDORSEMENT
WC090310 07/07 WC 09 03 10 FLORIDA EMPLOYEE LEASINGCOMPANY EXTENSION ENDORSEMENT
WC090606 10/98 WC 09 06 06 FLORIDA EMPLOYMENT AND WAGEINFORMATION RELEASE
WC090402 A 05/17 WC 09 04 02 A FLORIDA EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC090406 A 07/14 WC 09 04 06 A FLORIDA FOREIGN VOLUNTARYCOMPENSATION AND EMPLOYERSLIABILITY COVERAGE ENDORSEMENT
FORM095 10/19 FORM 09-5 FLORIDA INFORMATION PAGE NOTESWC090408 A 07/19 WC 09 04 08 A FLORIDA INSUFFICIENT FUNDS
ENDORSEMENTWC090201 01/15 WC 09 02 01 FLORIDA MARITIME COVERAGE
ENDORSEMENTWC090313 07/07 WC 09 03 13 FLORIDA MULTIPLE COORDINATED
POLICY ENDORSEMENTWC090407 07/13 WC 09 04 07 FLORIDA NON-COOPERATION WITH
PREMIUM AUDIT ENDORSEMENTFORM09 A 01/20 FORM 09 A-NOTICE FLORIDA NOTICE OF PENDING
LAW CHANGE TO TERRORISMRISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2007
WC090503 B 01/19 WC 09 05 03 B FLORIDA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC090504 B 01/19 WC 09 05 04 B FLORIDA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN - MULTIPLE LINES
WC090505 A 01/19 WC 09 05 05 A FLORIDA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
(New) WC090403 C 01/21 WC090403C FLORIDA TERRORISM RISK INSURANCEPROGRAM REAUTHORIZATION ACTENDORSEMENT
WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUMENDORSEMENT
WC090607 A 07/19 WC 09 06 07 A GUARANTY ASSOCIATION SURCHARGEENDORSEMENT
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC392 04/91 WC 00 03 20 LABOR CONTRACTOR ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC589 05/95 WC090501 RETRO PREMIUM END (FL)WC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC414 12/91 WC 00 05 05 A
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 30 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RETROSPECTIVE PREMIUMENDORSEMENT - LONG TERMCONSTRUCTION PROJECT
WC417 12/91 WC 00 05 14 A RETROSPECTIVE PREMIUMENDORSEMENT - LONG-TERMCONSTRUCTION PROJECT - MULTIPLELINES
WC144 04/84 WC 00 05 10 RETROSPECTIVE PREMIUMENDORSEMENT - NON-RATABLECATASTROPHE ELEMENT ORSURCHARGE
WC412 12/91 WC 00 05 03 A RETROSPECTIVE PREMIUMENDORSEMENT - ONE YEAR PLAN
WC415 12/91 WC 00 05 12 A RETROSPECTIVE PREMIUMENDORSEMENT - ONE YEAR PLAN -MULTIPLE LINES
WC090502 A 01/08 WC 09 05 02 A RETROSPECTIVE PREMIUMENDORSEMENT FOR NON-RATABLECATASTROPHE ELEMENT ORSURCHARGE
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC090309 01/06 WC 09 03 09 RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
GeorgiaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING
PLAN ENDORSEMENTWC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATING
PLAN NOTIFICATION ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT
WC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGEENDORSEMENT
WC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGEENDORSEMENT
WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC370 07/90 WC 10 06 02 BENEFITS DEDUCTIBLE ENDORSEMENTWC379 A 04/93 WC 10 06 01 A CANCELLATION, NON-RENEWAL, AND
CHANGE ENDORSEMENT(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIED
ACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC7729 03/94 FORMGID63 DISCLOSURE STATEMENT (FOR USE
WITH EXPERIENCE RATED INSUREDS)WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC100601 C 07/18 WC 10 06 01 C GEORGIA CANCELLATION,
NONRENEWAL, AND CHANGEENDORSEMENT
WC100301 11/99 WC 10 03 01 GEORGIA EMPLOYEE LEASINGENDORSEMENT
WC100402 01/13 WC 10 04 02 GEORGIA NON-COOPERATION WITHPREMIUM AUDIT ENDORSEMENT
WC100304 01/16 WC 10 03 04 GEORGIA PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXTENSIONENDORSEMENT
WC100302 01/16 WC 10 03 02 GEORGIA PROFESSIONAL EMPLOYERORGANIZATION (PEO) MASTER POLICYENDORSEMENT
WC100303 01/16 WC 10 03 03 GEORGIA PROFESSIONAL EMPLOYERORGANIZATION (PEO) MULTIPLECOORDINATED POLICY ENDORSEMENTFOR POLICY COVERING THE PEO
WC100501 B 01/19 WC 10 05 01 B GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT ONE-YEAR PLAN
WC100504 B 01/19 WC 10 05 04 B GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT ONE-YEAR PLAN—MULTIPLE LINES
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 32 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC100502 B 01/19 WC 10 05 02 B GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT THREE-YEAR PLAN
WC100505 B 01/19 WC 10 05 05 B GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT THREE-YEAR PLAN—MULTIPLE LINES
WC100503 B 01/19 WC 10 05 03 B GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT WRAP-UP CONSTRUCTION PROJECT
WC100506 B 01/19 WC 10 05 06 B GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENTWRAP–UP CONSTRUCTION PROJECT—MULTIPLE LINES
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC536 01/94 WC100401 MERIT RATING END [GA]WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 33 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
HawaiiWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC112 04/84 WC 00 03 01 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 34 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
AUDIT NONCOMPLIANCE CHARGEENDORSEMENT
WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR
OWNERSHIP INFORMATIONWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC583 01/96 WC520403 CONTRACTING CLASSIFICATION
PREMIUM ADJUSTMENT ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUMENDORSEMENT
WC520602 01/96 WC 52 06 02 HAWAII NOTIFICATION ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC329 A 10/89 WC 52 06 01 A MEDICAL BENEFITS DEDUCTIBLE
ENDORSEMENTWC341 03/87 WC 52 04 02 MERIT RATING (HI)WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 35 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC267 07/91 WC 00 04 10 PREMIUM DETERMINATIONENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC597 02/97 WC000326 RESIDUAL MARKET LIMITED OTHER
STATES INSURANCE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 36 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC140 04/84 WC 52 04 01 VOLUNTEER WORKERS ENDORSEMENTWC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROM
OTHERS ENDORSEMENTIdaho
WC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM
ENDORSEMENTWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING
PLAN ENDORSEMENTWC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATING
PLAN NOTIFICATION ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC458 09/92 WC 11 04 01 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENT - TOTAL MODIFIEDPREMIUM BASIS
WC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGEENDORSEMENT
WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIED
ACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC110402 A 07/11 WC 11 04 02 A IDAHO ALCOHOL-AND DRUG-FREE
WORKPLACE PREMIUM CREDITENDORSEMENT
WC110601 07/99 WC 11 06 01
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 37 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
IDAHO COMPENSATIONREIMBURSEMENT OPTIONENDORSEMENT
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 38 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RETRO PREMIUM ENDORSEMENT—SHORT FORM
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
IllinoisWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC120601 F 01/19 WC 12 06 01 F AMENDATORY END (IL)WC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM
ENDORSEMENTWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING
PLAN ENDORSEMENTWC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATING
PLAN NOTIFICATION ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT
(New) WC000421 E 01/21 WC000421E
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 39 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC464 09/92 WC 12 04 02 CONTRACTING CLASS PREM ADJ [ILWC644 12/03 FORM121CCPAP CONTRACTING CLASSIFICATION
PREMIUM ADJUSTMENT PROGRAM(ILCCPAP) CONFIDENTIAL WORKERSCOMPENSATION PREMIUM CREDITAPPLICATION
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC120303 A 06/03 WC 12 03 03 A EMPLOYEE LEASING ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC120304 06/99 WC 12 03 04 IL EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC120305 06/99 WC 12 03 05 IL LABOR CONTRACTOR EXCLUSION
ENDORSEMENTWC120308 01/17 WC 12 03 08 ILLINOIS PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXTENSIONENDORSEMENT
WC120309 01/17 WC 12 03 09 ILLINOIS PROFESSIONAL EMPLOYERORGANIZATION (PEO) MASTER POLICYENDORSEMENT
WC120603 01/19 WC 12 06 03 ILLINOIS RENEWAL ENDORSEMENTWC120307 06/15 WC 12 03 07 ILLINOIS SOLE PROPRIETORS,
PARTNERS, OFFICERS, MEMBERSOF LIMITED LIABILITY COMPANIES,AND OTHER EXCLUDED EMPLOYEESAND EMPLOYMENTS EXCLUSIONENDORSEMENT
WC120306 A 07/11 WC 12 03 06 A ILLINOIS WORKERS COMPENSATIONAND EMPLOYERS LIABILITY INSURANCEPOLICY EXCLUSION ENDORSEMENT
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 40 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC150 A 08/92 WC 12 06 02 A MED DEDUCT END [IL]WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
FORM635 L 11/11 635L NEW YORK WORKERS COMPENSATIONPREMIUM CREDIT APPLICATION
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 41 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
IndianaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING
PLAN ENDORSEMENTWC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATING
PLAN NOTIFICATION ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC430 01/92 WC 13 06 04 BENEFITS DEDUCTIBLE ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
WC431 01/92 WC 13 06 02 COINSURANCE AND DEDUCTIBLEENDORSEMENT
WC432 01/92 WC 13 06 03 COINSURANCE ENDORSEMENTERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR
OWNERSHIP INFORMATIONWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 42 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 43 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—AVIATION
WC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—CHANGES
WC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—SHORT FORM
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
IowaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM
ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 44 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC140602 07/02 WC 14 06 02 IOWA EXECUTIVE OFFICERS, SOLE
PROPRIETORS, PARTNERS, MEMBERSAND MANAGERS OF LIMITED LIABILITYCOMPANIES AND OTHERS, BENEFITLEVEL SELECTION ENDORSEMENT
WC140603 01/11 WC 14 06 03 IOWA MEDICAL DEDUCTIBLE PROGRAM—CARRIER REIMBURSED DEDUCTIBLEENDORSEMENT
WC116 04/84 WC 00 03 05 JOINT VENTURE AS INSUREDENDORSEMENT
WC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSIONENDORSEMENT
WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGEENDORSEMENT
WC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TO
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 45 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC597 02/97 WC000326 RESIDUAL MARKET LIMITED OTHER
STATES INSURANCE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC141 04/84 WC 00 05 05 RETROSPECTIVE PREMIUM
ENDORSEMENT - RATING OPTIONS V -LONG TERM CONSTRUCTION PROJECT
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 46 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
KansasWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM
ENDORSEMENTWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING
PLAN ENDORSEMENTWC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATING
PLAN NOTIFICATION ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC150403 F 01/15 WC 15 04 03 F ASSIGNED RISK RETROSPECTIVE
RATING PLAN ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC152 A 01/87 WC 15 06 01 A CANCELLATION AND NONRENEWAL
ENDORSEMENT(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIED
ACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC312 03/85 WC 15 03 01 DOMESTIC AND AGRICULTURAL
WORKERS’ EXCLUSION ENDORSEMENTWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 47 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC621 03/98 WC150407A0198 KANSAS ASSIGNED RISKWC150408 A 01/16 WC 15 04 08 A KANSAS ASSIGNED RISK SMALL
EMPLOYER LOSS-FREE POLICYPREMIUM CREDIT ENDORSEMENT
WC150302 01/05 WC 15 03 02 KANSAS HOME AND COMMUNITYBASED SERVICES WAIVER PROGRAMENDORSEMENT
WC150603 07/06 WC 15 06 03 KANSAS PER CLAIMANT BENEFITSDEDUCTIBLE ENDORSEMENT
WC150602 07/06 WC 15 06 02 KANSAS PER OCCURRENCE BENEFITSDEDUCTIBLE ENDORSEMENT
WC150303 B 05/17 WC 15 03 03 B KANSAS PROFESSIONAL EMPLOYERORGANIZATION (PEO) MULTIPLECOORDINATED POLICY ENDORSEMENTFOR POLICY COVERING THE PEO
WC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSIONENDORSEMENT
WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGEENDORSEMENT
WC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC586 03/96 WC150405 LOSS COST CHANGE ENDORSEMENTWC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC585 03/96 WC150404 PENDING LOSS COST (KS)
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 48 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTPN049901 G 03/19 PN 04 99 01 G POLICYHOLDER NOTICE (YOUR
RIGHT TO RATING AND DIVIDENDINFORMATION)
WC266 07/91 WC 00 04 09 PREMIUM DETERMINATIONENDORSEMENT - FORMER SELF-INSURERS 1
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC597 02/97 WC000326 RESIDUAL MARKET LIMITED OTHER
STATES INSURANCE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 49 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
KentuckyWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR
OWNERSHIP INFORMATIONWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC610 05/97 WC1603030597 EMPLOYEE LEASING (KY)WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC160302 B 05/17 WC 16 03 02 B EMPLOYEE LEASING ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM
ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC618 12/97 WC1606011297 KENTUCKY CANC/NONREN ENDWC160602 10/99 WC 16 06 02 KENTUCKY NOTICE OF APPEAL RIGHTS
ENDORSEMENTWC160305 06/07 WC 16 03 05
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
KENTUCKY PART ONE WORKERSCOMPENSATION INSURANCEENDORSEMENT
WC611 05/97 WC1603040597 LABOR CONT EXCL END(KY)WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSION
ENDORSEMENTWC118 04/84 WC 00 03 07 MEDICAL BENEFITS REIMBURSEMENT
ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC549 05/97 WC1603010597 REJECTION OF COVERAGE
ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RETRO PREMIUM ENDORSEMENT—CHANGES
WC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—SHORT FORM
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
LouisianaWC126 04/84 WC 00 04 01 AIRCRAFT PREMIUM ENDORSEMENTWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC537 A 02/96 WC170602A COST CONT ACT END (LA)WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
EMPLOYEE LEASING CLIENTENDORSEMENT
WC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC170601 J 08/18 WC 17 06 01 J LOUISIANA AMENDATORYENDORSEMENT
WC170401 11/04 WC 17 04 01 LOUISIANA ANNIVERSARY RATINGDATE ENDORSEMENT
WC170303 12/00 WC 17 03 03 LOUISIANA DUTY TO DEFENDENDORSEMENT
WC170304 02/03 WC 17 03 04 LOUISIANA PROFESSIONAL EMPLOYERORGANIZATION ENDORSEMENT
WC170305 02/03 WC 17 03 05 LOUISIANA PROFESSIONAL EMPLOYERORGANIZATION EXCLUSIONENDORSEMENT
WC170501 C 01/19 WC 17 05 01 C LOUISIANA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT ONE-YEAR PLAN
WC170504 C 01/19 WC 17 05 04 C LOUISIANA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT ONE-YEAR PLAN—MULTIPLE LINES
WC170502 C 01/19 WC 17 05 02 C LOUISIANA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT THREE-YEAR PLAN
WC170505 C 01/19 WC 17 05 05 C LOUISIANA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT THREE-YEAR PLAN - MULTIPLE LINES
WC170503 C 01/19 WC 17 05 03 C LOUISIANA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT WRAP-UP CONSTRUCTION PROJECT
WC170506 C 01/19 WC 17 05 06 C LOUISIANA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT WRAP-
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
UP CONSTRUCTION PROJECT - MULTIPLELINES
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSION
ENDORSEMENTWC118 04/84 WC 00 03 07 MEDICAL BENEFITS REIMBURSEMENT
ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
MaineWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC599 09/96 WC1804070996 ANNIV MODIFICATION (ME)WC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC357 D 12/97 WC 18 06 02 D BENEFITS DEDUCTIBLE ENDORSEMENTWC360 A 06/95 WC 18 06 03 A CANC & NONREN END (ME)
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC395 05/88 WC 18 06 04 FINAL PREM AUD END (ME)WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC153 04/84 WC 18 06 01 INSPECTION IMMUNITY ENDORSEMENTWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC180606 08/99 WC 18 06 06 MAINE NOTICE OF FILING OF FIRSTREPORTS OF INJURY
WC180607 A 07/11 WC 18 06 07 A MAINE SUPPLEMENTAL BENEFITS FUNDENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC356 11/87 WC 18 04 02 A MERIT RAT ENDT [ME]WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
MarylandWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT
WC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGEENDORSEMENT
WC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGEENDORSEMENT
WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC190601 G 10/17 WC 19 06 01 G CANCELLATION ENDORSEMENT (MD)
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC476 07/93 WC 19 04 01 CONST CLASS PREM [MD]WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC190402 A 10/17 WC 19 04 02 A MARYLAND ALCOHOL- AND DRUG-
FREE WORKPLACE PREMIUM CREDITENDORSEMENT
WC190602 01/14 WC 19 06 02 MARYLAND NOTIFICATION OF 45-DAYUNDERWRITING PERIOD ENDORSEMENT
WC448 07/92 WC 00 01 11 MIGRANT AND SEASONALAGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
SOLEPROP 01/10 WCC FORM IC-02 SOLE PROPRIETOR'S STATUS AS ACOVERED EMPLOYEE
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
MassachusettsWC126 04/84 WC 00 04 01 AIRCRAFT PREMIUM ENDORSEMENTWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC474 01/93 WC 20 06 02 BENEFITS DET END [MA]WC386 01/91 WC 20 04 03 CONSTRUCTION CLASSIFICATIONWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC1032 05/19 EXPLANATION OF AUDIT
NONCOMPLIANCE CHARGEWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM
ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
INSURANCE COMPANY AS INSUREDENDORSEMENT
WC116 04/84 WC 00 03 05 JOINT VENTURE AS INSUREDENDORSEMENT
WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGEENDORSEMENT
WC200306 B 06/13 WC 20 03 06 B LIMITED OTHER STATES BENEFITENDORSEMENT
WC242 04/84 WC 20 03 01 LIMITS OF LIABILITY ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC200307 11/02 WC 20 03 07 MASSACHUSETTS ASSIGNED RISK POOL
ELIGIBILITY ENDORSEMENTWC200603 A 04/15 WC 20 06 03 A MASSACHUSETTS BENEFITS CLAIM
AND AGGREGATE DEDUCTIBLEENDORSEMENT
WC200601 07/08 WC 20 06 01 A MASSACHUSETTS CANCELATIONENDORSEMENT
WC652 B 11/11 MASSACHUSETTS CONSTRUCTIONCLASSIFICATION PREMIUMADJUSTMENT PROGRAM WORKERS’COMPENSATION PREMIUM CREDITAPPLICATION
WC200304 C 04/19 WC 20 03 04 C MASSACHUSETTS EMPLOYEE LEASINGENDORSEMENT
WC200305 A 01/17 WC 20 03 05 A MASSACHUSETTS EXCLUSION OFCOVERAGE FOR LEASED EMPLOYEESENDORSEMENT (LABOR CONTRACTORS)
WC200102 01/14 WC 20 01 02 MASSACHUSETTS NOTIFICATIONENDORSEMENT OF PENDINGLAW CHANGE TO TERRORISMRISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2007
WC200604 11/02 WC 20 06 04 MASSACHUSETTS POLICY DEFINITIONENDORSEMENT
WC200405 06/01 WC 20 04 05 MASSACHUSETTS PREMIUM DUE DATEENDORSEMENT
WC200101 01/08 WC 20 01 01 MASSACHUSETTS TERRORISMRISK INSURANCE PROGRAMREAUTHORIZATION ACT ENDORSEMENT
WC200302 A 09/08 WC 20 03 02 A MASSACHUSETTS-ASSESSMENTCHARGE
WC448 07/92 WC 00 01 11 MIGRANT AND SEASONALAGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC200303 D 08/10 WC 20 03 03 D NOTICE TO POLICYHOLDERENDORSEMENT
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC380 11/90 WC 20 04 01 PENDING PREMIUM CHANGEENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC267 07/91 WC 00 04 10 PREMIUM DETERMINATIONENDORSEMENT - FORMER SELF-INSURERS 2
WC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC418 B 01/94 WC 20 04 02 B QUAL LOSS MGMT [MA]WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC571 04/95 WC200501 RETRO PREM END [MA]WC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC122 B 08/91 WC 00 03 11 B
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 62 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
MichiganWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC112 04/84 WC 00 03 01 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC509 04/84 WC 21 03 01 DESIGNATED CONSTRUCTION SITE
COVERAGE ENDORSEMENTWC510 04/84 WC 21 03 02 DESIGNATED CONSTRUCTION SITE
EXCLUSION ENDORSEMENTWC511 04/84 WC 21 03 05 DESIGNATED CONSTRUCTION SITE
EXCLUSION ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC170 04/84 WC 21 06 04 DUAL OR JOINT EMPLOYEE
ENDORSEMENTWC516 04/84 WC 21 06 01 DUAL/JOINT EMP END [MI]WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC103 04/84 WC 00 01 04 FEDERAL EMPLOYERS' LIABILITY ACT
COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC491 04/84 WC 21 03 04 LAW ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 63 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSION
ENDORSEMENTWC118 04/84 WC 00 03 07 MEDICAL BENEFITS REIMBURSEMENT
ENDORSEMENTWC210503 A 06/97 WC 21 05 03 A MICHIGAN RETRO PREM ENDWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC171 A 01/87 WC 21 05 01A NON-RATABLE SPECIFIC DISEASEELEMENT (SUPPLEMENT TORETROSPECTIVE PREMIUMENDORSEMENT)
WC210303 A 06/97 WC 21 03 03 A NOTICE TO POLICYHOLDERENDORSEMENT
WC210102 A 01/20 WC 21 01 02 A NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2007
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC514 04/84 WC 21 04 01 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELFINSURERS
WC267 07/91 WC 00 04 10 PREMIUM DETERMINATIONENDORSEMENT - FORMER SELF-INSURERS 2
WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC172 04/84 WC 21 05 02 RETRO PREM END [MI]WC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC144 04/84 WC 00 05 10
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RETROSPECTIVE PREMIUMENDORSEMENT - NON-RATABLECATASTROPHE ELEMENT ORSURCHARGE
WC141 04/84 WC 00 05 05 RETROSPECTIVE PREMIUMENDORSEMENT - RATING OPTIONS V -LONG TERM CONSTRUCTION PROJECT
WC137 04/84 WC 00 05 03 RETROSPECTIVE PREMIUMENDORSEMENT - RATING OPTIONS V -ONE YEAR PLAN
WC650 04/84 WC000509 RETROSPECTIVE PREMIUMENDORSEMENT CHANGES
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000501 04/84 WC 00 05 01 RETROSPECTIVE-1YR PLAN-OPTION I, II,III & IV
WC000502 04/84 WC 00 05 02 RETROSPECTIVE-3YR PLAN-OPTION I, II,III & IV
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC210402 B 01/15 WC 21 04 02 B TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC530 04/84 WC210101 VOL COMP FED EMP [MI]WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION AND
EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
WC320 10/85 WC 21 06 05 WAIVER/COORD BEN [MI]WC512 01/85 WC 21 03 06 WORKERS’ COMPENSATION PLACEMENT
FACILITY - LIMITS OF LIABILITYENDORSEMENT
MinnesotaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC220000 A 11/03 WC 22 00 00 A AMENDATORY ENDORSEMENT (MN)WC580 09/95 WC220402 ANNIVERSARY RATING DATE
ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT
WC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGEENDORSEMENT
WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC220601 D 08/06 WC 22 06 01 D CANCELLATION AND NONRENEWAL
ENDORSEMENTWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC438 10/92 WC 22 04 01 CONTRACT PREM ADJ [MN]WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM
ENDORSEMENTWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC220306 08/09 WC 22 03 06 MINNESOTA ALTERNATE EMPLOYERENDORSEMENT [EXCLUDINGEMPLOYERS LIABILITY COVERAGE]
WC220301 01/05 WC 22 03 01 MINNESOTA COMPLIANCE WITHAPPLICABLE TRADE SANCTION LAWSENDORSEMENT
WC220304 01/06 WC 22 03 04 MINNESOTA EMPLOYEE LEASINGENDORSEMENT
WC220620 01/05 WC 22 06 20 MINNESOTA ENTITY ADDRESSSCHEDULE ENDORSEMENT
WC220305 01/06 WC 22 03 05 MINNESOTA EXCLUSION OFCOVERAGE FOR LEASED EMPLOYEESENDORSEMENT
WC220001 09/02 WC 22 00 01 MINNESOTA INFORMATION PAGE ANDNOTES
WC220303 01/06 WC 22 03 03
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
MINNESOTA THIRD DEGREE OFKINDRED FAMILY MEMBER EXCLUSIONENDORSEMENT
WC220302 01/05 WC 22 03 02 MINNESTOA INDEPENDENTCONTRACTORS COVERAGEENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC220600 01/02 WC 22 06 00 POLICY CHANGE ENDORSEMENTWC220616 A 10/07 WC 22 06 16 A POLICY CHANGE ENDORSEMENTWC220611 01/02 WC 22 06 11 POLICY INFORMATION PAGE
ENDORSEMENT - ADD STATESWC220619 01/02 WC 22 06 19 POLICY INFORMATION PAGE
ENDORSEMENT - CARRIER NUMBERWC220617 01/02 WC 22 06 17 POLICY INFORMATION PAGE
ENDORSEMENT - CARRIER SERVICINGOFFICE
WC220613 01/02 WC 22 06 13 POLICY INFORMATION PAGEENDORSEMENT - CHANGE IN STATE
WC220609 01/02 WC 22 06 09 POLICY INFORMATION PAGEENDORSEMENT - CHANGE INWORKPLACE OF INSURED
WC220615 A 10/07 WC 22 06 15 A POLICY INFORMATION PAGEENDORSEMENT - CLASS, RATE, OTHERCHANGE
WC220604 01/02 WC 22 06 04 POLICY INFORMATION PAGEENDORSEMENT - EFFECTIVE DATE
WC220612 01/02 WC 22 06 12 POLICY INFORMATION PAGEENDORSEMENT - EMPLOYER LIMITS
WC220614 01/02 WC 22 06 14 POLICY INFORMATION PAGEENDORSEMENT - ENDORSEMENTNUMBERS
WC220607 01/02 WC 22 06 07 POLICY INFORMATION PAGEENDORSEMENT - EXPERIENCEMODIFICATION
WC220605 01/02 WC 22 06 05 POLICY INFORMATION PAGEENDORSEMENT - EXPIRATION DATE
WC220610 01/02 WC 22 06 10 POLICY INFORMATION PAGEENDORSEMENT - INSURED'S LEGALSTATUS
WC220606 01/02 WC 22 06 06 POLICY INFORMATION PAGEENDORSEMENT - INSURED'S MAILINGADDRESS
WC220602 01/02 WC 22 06 02 POLICY INFORMATION PAGEENDORSEMENT - INSURED'S NAME
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC220618 01/02 WC 22 06 18 POLICY INFORMATION PAGEENDORSEMENT - INTERSTATE /INTRASTATE RISK I.D. NUMBER
WC220603 01/02 WC 22 06 03 POLICY INFORMATION PAGEENDORSEMENT - POLICY NUMBER
WC220608 01/02 WC 22 06 08 POLICY INFORMATION PAGEENDORSEMENT - PRODUCER'S NAME
WC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC267 07/91 WC 00 04 10 PREMIUM DETERMINATIONENDORSEMENT - FORMER SELF-INSURERS 2
WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC547 02/94 WC000309A RURAL ELECTRIFICATIONADMINISTRATION ENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC122 B 08/91 WC 00 03 11 B
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
MississippiWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING
PLAN ENDORSEMENTWC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATING
PLAN NOTIFICATION ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC230601 07/18 WC 23 06 01 MISSISSIPPI CANCELLATION,NONRENEWAL, AND RENEWALENDORSEMENT
WC230402 03/16 WC 23 04 02 MISSISSIPPI PAY-AS-YOU-GO PROGRAMENDORSEMENT
WC230401 A 07/17 WC 23 04 01 A MISSISSIPPI-SMALL EMPLOYER LOSS-FREE POLICY PREM C
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
MissouriWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC112 04/84 WC 00 03 01 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC439 09/91 WC 24 04 02 ASSIGNED RISK PREMIUMWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC579 10/95 WC2406031095 BENEFITS DED END (MO)WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC158 B 01/96 WC 24 06 01 B CANCELLATION AND NONRENEWAL
ENDORSEMENTWC368 01/90 WC 24 04 01 CONT CLASS PREM AS [MO]WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSION
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC240406 D 08/16 WC 24 04 06 D EMPLOYER PAID MEDICAL END (MO)WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM
ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC240604 C 09/19 WC 24 06 04 C MISSOURI AMENDATORYENDORSEMENT
FORM24-1 B 08/16 FORM 24-1 B MISSOURI CONTRACTINGCLASSIFICATION PREMIUMADJUSTMENT PROGRAM WORKERSCOMPENSATION - PREMIUM CREDITAPPLICATION
WC240303 A 01/14 WC 24 03 03 MISSOURI EXCLUSION OF ADDITIONALMESOTHELIOMA BENEFITSENDORSEMENT
WC240302 A 01/14 WC 24 03 02 MISSOURI NOTIFICATION OFADDITIONAL MESOTHELIOMA BENEFITSENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC240602 B 07/06 WC 24 06 02 B P&C GUARANTY ASSOCIATIONNOTIFICATION ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC890600 B 07/01 WC890600B POLICY INFORMATION PAGEENDORSEMENT
WC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLECOMPANY ENDORSEMENT
WC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—AVIATION
WC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—CHANGES
WC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—SHORT FORM
WC157 A 12/91 WC 24 05 01 A RETROSPECTIVE PREMIUMSUPPLEMENTAL ENDORSEMENT
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC122 B 08/91 WC 00 03 11 B
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
MontanaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC250601 B 04/16 WC 25 06 01 B CANCEL & NONRENEWAL ENDT (MT)
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
NC5000 D 08/19 NC-5000 D CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT PROGRAMWORKERS COMPENSATION PREMIUMCREDIT APPLICATION
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSIONENDORSEMENT
WC118 04/84 WC 00 03 07 MEDICAL BENEFITS REIMBURSEMENTENDORSEMENT
WC448 07/92 WC 00 01 11 MIGRANT AND SEASONALAGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC250302 10/99 WC 25 03 02 MONTANA EMPLOYEE LEASING/PROFESSIONAL EMPLOYER CLIENTEXCLUSION ENDORSEMENT
WC250301 A 05/17 WC 25 03 01 A MONTANA EMPLOYEE LEASING/PROFESSIONAL EMPLOYERENDORSEMENT
WC250305 07/02 WC 25 03 05 MONTANA INTENTIONAL INJURYEXCLUSION ENDORSEMENT
WC250303 10/99 WC 25 03 03 MONTANA LABOR CONTRACTOR/PROFESSIONAL EMPLOYERORGANIZATION EXCLUSIONENDORSEMENT
WC250401 A 01/17 WC 25 04 01 A MONTANA NON-COOPERATIONWITH PREMIUM AUDIT SURCHARGEENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RETRO PREMIUM ENDORSEMENT—AVIATION
WC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—CHANGES
WC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—SHORT FORM
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC542 01/94 WC250602 SAFETY END (MT)WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,
OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
NebraskaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC337 C 07/96 WC 26 06 01 C CANC & NONREN END(NE)
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
NC5000 D 08/19 NC-5000 D CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT PROGRAMWORKERS COMPENSATION PREMIUMCREDIT APPLICATION
WC304 01/95 WC 26 04 02 CONTRACTION CLASS [NE]WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC381 05/89 WC 26 04 01 EXPERIENCE RATING MODIFICATION
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC393 07/90 WC 26 06 02 MED BENEFITS END [NE]WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC260401 B 05/17 WC 26 04 01 B NEBRASKA EXPERIENCE RATINGMODIFICATION ENDORSEMENT
WC260403 05/17 WC 26 04 03 NEBRASKA EXPERIENCE RATINGMODIFICATION FACTOR REVISIONENDORSEMENT
WC260303 05/13 WC 26 03 03 NEBRASKA PROFESSIONAL EMPLOYERORGANIZATION (PEO) CLIENTEXCLUSION ENDORSEMENT
WC260304 05/13 WC 26 03 04 NEBRASKA PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC260302 A 05/17 WC 26 03 02 A NEBRASKA PROFESSIONAL EMPLOYERORGANIZATION (PEO) MULTIPLECOORDINATED POLICY ENDORSEMENTFOR POLICY COVERING THE CLIENT
WC260301 A 05/17 WC 26 03 01 A NEBRASKA PROFESSIONAL EMPLOYERORGANIZATION (PEO) MULTIPLECOORDINATED POLICY ENDORSEMENTFOR POLICY COVERING THE PEO
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000309 B 01/06 WC 00 03 09 B
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
NevadaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM
ENDORSEMENTWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING
PLAN ENDORSEMENTWC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATING
PLAN NOTIFICATION ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTES
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSUREDENDORSEMENT
WC116 04/84 WC 00 03 05 JOINT VENTURE AS INSUREDENDORSEMENT
WC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSIONENDORSEMENT
WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGEENDORSEMENT
WC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC270601 C 10/08 WC 27 06 01 C NEVADA CANCEL/NONRENEWAL ENDTWC270302 A 06/12 WC 27 03 02 A NEVADA EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC270303 A 06/12 WC 27 03 03 A NEVADA EMPLOYEE LEASING
EXCLUSION ENDORSEMENTWC270304 A 03/16 WC 27 03 04 A NEVADA EMPLOYEE LEASING MASTER
POLICY BASIS ENDORSEMENTWC270301 C 05/17 WC 27 03 01 C NEVADA EMPLOYEE LEASING MULTIPLE
COORDINATED POLICIES BASISENDORSEMENT
WC270501 A 01/19 WC 27 05 01 A NEVADA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC270502 A 01/19 WC 27 05 02 A NEVADA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 80 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
PREMIUM DETERMINATIONENDORSEMENT - FORMER SELF-INSURERS 1
WC267 07/91 WC 00 04 10 PREMIUM DETERMINATIONENDORSEMENT - FORMER SELF-INSURERS 2
WC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
New HampshireWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC447 04/92 WC 28 06 04 AMENDATORY ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC477 12/92 WC 28 04 01 ASSIGN RISK SUR [NH]WC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM
ENDORSEMENTWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING
PLAN ENDORSEMENTWC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATING
PLAN NOTIFICATION ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
WC280402 A 07/03 WC 28 04 02 A CERTIFIED MANAGED CARE (NH)ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR
OWNERSHIP INFORMATIONWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC280404 01/08 WC 28 04 04 PENDING RATE CHANGE ENDORSEMENTWC446 03/92 WC 28 06 03 PER ACCID PER DIS (NH)WC445 03/92 WC 28 06 02 PER CLAIM BENE END (NH)WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC365 A 01/96 WC 28 04 03 A SAFETY INC PROG (NH)WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,
OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC200 04/84 WC 28 06 01 SOLE REPRESENTATIVE ENDORSEMENT(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAM
REAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
WC280301 B 01/09 WC 28 03 01 B WC/EMPLOYERS LIABILITY COVERAGERES [NH]
New JerseyWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC531 A 01/96 WC290409A APPROVED MANAGED CARE PROGRAM
ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC577 04/96 WC290410 CONSTRUCTION CLASSIFICATIONWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000425 05/17 WC 00 04 25
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUMENDORSEMENT
WC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSUREDENDORSEMENT
WC116 04/84 WC 00 03 05 JOINT VENTURE AS INSUREDENDORSEMENT
NJLRLD 07/06 FORMNJLRLD LARGE RISK - LARGE DEDUCTIBLEPROGRAM NOTICE OF ELECTION
WC497 A 01/94 WC 29 06 01 A LG RISK DED END [NJ]WC290309 A 07/05 WC 29 03 09 A LIMIT OTHER STATE INS ENDT(NJ)WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC290311 04/18 WC 29 03 11 NEW JERSEY EMPLOYEE LEASINGCLIENT ENDORSEMENT
WC290304 A 04/18 WC 29 03 04 A NEW JERSEY EMPLOYEE LEASINGCLIENT EXCLUSION ENDORSEMENT
WC290303 04/18 WC 29 03 03 NEW JERSEY EMPLOYEE LEASINGLABOR CONTRACTOR ENDORSEMENT
WC290305 A 04/18 WC 29 04 11 D NEW JERSEY EMPLOYEE LEASINGLABOR CONTRACTOR EXCLUSIONENDORSEMENT
WC290605 01/05 WC 29 06 05 NEW JERSEY LARGE RISK - LARGEDEDUCTIBLE ENDORSEMENT PERPERSON BASIS
WC290307 04/00 WC 29 03 07 NEW JERSEY SOLE PROPRIETORS ANDPARTNERS COVERAGE ENDORSEMENT
WC290302 B 01/20 WC 29 03 02 B NEW JERSEY WORKERS COMPENSATIONAND EMPLOYERS LIABILITY COVERAGEFOR RESIDENCE EMPLOYEESENDORSEMENT
WC290310 07/04 WC 29 03 10 NEW JERSEY WORKERS' COMPENSATIONINSURANCE PLAN ELIGIBILITYENDORSEMENT
WC290604 A 01/19 WC 29 06 04 A NJ LARGE RISK - LARGE DEDUCTIBLEAGGREGATE LIMIT ENDORSEMENT
WC614 01/98 WC290603 NJ PARTICIPATING PROV ENDWC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUND
INSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC106 01/89 NOTICEWC290312 05/18 WC 29 03 12
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
NOTICE OF CANCELLATION ORMATERIAL COVERAGE CHANGE TODESIGNATED GOVERNMENTAL ENTITYENDORSEMENT
FORMPP1 B 07/07 FORMPP1B NOTICE OF ELECTION - PROPRIETORSAND PARTNERS WORKERS'COMPENSATION AND EMPLOYERS'LIABILITY INSURANCE
NJRR2 01/16 NJRR-2 NOTICE OF ELECTION OFRETROSPECTIVE RATING (MUST BEFILED WITH NJCRIB)
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC290306 B 07/07 WC 29 03 06 B PART 2 EMPLOYERS LIABILITYENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC205 A 01/86 WC 29 04 07 PREMIUM DISCOUNT ENDORSEMENT -
SCHEDULE XWC290406 Y 01/12 WC 29 04 06 Y PREMIUM DISCOUNT ENDORSEMENT
SCHEDULE YWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC290509 C 07/00 WC 29 05 09 C RETRO PREM ENDT PRT2 EXC (NJ)WC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC290602 B 01/05 WC 29 06 02 B RETROSPECTIVE ADJUSTMENT
ENDORSEMENTWC290513 C 01/05 WC 29 05 13 C RETROSPECTIVE PREM 1 YEAR (NJ)WC290514 C 01/05 WC 29 05 14 C RETROSPECTIVE PREMIUM 3YRWC290515 C 01/05 WC 29 05 15 C RETROSPECTIVE PREMIUM
ENDORSEMENTWC144 04/84 WC 00 05 10 RETROSPECTIVE PREMIUM
ENDORSEMENT - NON-RATABLECATASTROPHE ELEMENT ORSURCHARGE
WC137 04/84 WC 00 05 03 RETROSPECTIVE PREMIUMENDORSEMENT - RATING OPTIONS V -ONE YEAR PLAN
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC650 04/84 WC000509 RETROSPECTIVE PREMIUMENDORSEMENT CHANGES
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC201 04/84 WC 29 01 01 VOL COMP FED [NJ]WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION AND
EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
New MexicoWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM
ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR
OWNERSHIP INFORMATIONWC300305 09/07 WC 30 03 05 CONSUMER DIRECTED PROGRAM
ENDORSEMENTWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTNC5001 01/11 FORM NC-5001 CONTRACTING CLASSIFICATION
PREMIUM ADJUSTMENT PROGRAMAPPLICATION FOR NON-ARD STATES
NC5000 D 08/19 NC-5000 D CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT PROGRAM
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WORKERS COMPENSATION PREMIUMCREDIT APPLICATION
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUMENDORSEMENT
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC300402 01/05 WC 30 04 02 NEW MEXICO ASSIGNED RISKSURCHARGE ENDORSEMENT
WC300601 A 03/15 WC 30 06 01 A NEW MEXICO CANCELLATION ANDNONRENEWAL ENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC159 04/84 WC 30 03 01 SAFETY DEVICE COVERAGEENDORSEMENT
WC160 04/84 WC 30 03 02 SAFETY DEVICE EXCLUSIONENDORSEMENT
WC121 04/84 WC 00 03 10
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC161 04/84 WC 30 03 03 VOLUNTEER WORKER ENDORSEMENTWC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROM
OTHERS ENDORSEMENTWC459 A 07/93 WC 30 04 01 A WC PREM ADJ PROG [NM]
New YorkWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC488 01/89 WC 31 06 12 AMBULANCE/FIRE D [NY]WC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC402 A 04/94 WC 31 03 15 A BENEFITS DED END (NY)WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC473 04/93 WC 31 04 01 CONS CLASS PREM AD [NY]WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC219 04/84 WC 31 03 02 DESIGNATED WORKPLACE(NY)WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC220 04/84 WC 31 06 01 DOMESTIC WORKERS (NY)WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC423 04/92 WC 00 03 03 B EMPLOYERS’ LIABILITY COVERAGE
ENDORSEMENTWC223 B 01/94 WC 31 03 05 B EXCL OF EXEC OFF (NY)WC222 04/84 WC 31 06 02 EXCLUSION DES [NY]WC224 01/86 WC 31 03 04 EXEC OFF EXCL [NY]WC225 04/84 WC 31 06 03 EXECUTIVE OFFICERS [NY]WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM
ENDORSEMENTWC310314 A 08/00 WC 31 03 14 A INCLUSION OF AUXILIARY POLICY
ENDORSEMENTWC227 A 01/87 WC 31 03 06 A INCLUSION OF EXEC (NY)WC310003 B 05/20 WC310003B
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
INFORMATION PAGE - VOLUNTEERAMBULANCE WORKERS’ BENEFITPOLICY
WC310001 B 05/20 WC310001B INFORMATION PAGE - VOLUNTEERFIREFIGHTERS’ BENEFIT POLICY
WC9941 B 05/20 WC000001E INFORMATION PAGE NOTESWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC228 04/84 WC 31 03 07 LIABILITY OF MUNICIPALITIES
TO POLICE OFFICERS OR PAIDFIREFIGHTERS - EXCLUSIONENDORSEMENT
WC230 04/84 WC 31 03 09 LIMIT OF LIAB END [NY]WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC231 04/84 WC 31 03 10 MEDICAL BENEFITS REIMBURSEMENT
ENDORSEMENTWC554 10/94 WC310402 MERIT RATING ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC310609 A 05/20 WC310609A NEW YORK AMBULANCE DISTRICTLIABILITY EXCLUSION ENDORSEMENTFOR COUNTY OR TOWN POLICIES
WC310319 J 05/20 WC 31 03 19 J NEW YORK CONSTRUCTIONCLASSIFICATION PREMIUMADJUSTMENT PROGRAM EXPLANATORYENDORSEMENT
WC310301 A 05/20 WC310301A NEW YORK COVERAGE FOR ELECTEDOR APPOINTED OFFICERS OF MUNICIPALCORPORATIONS OR OTHER POLITICALSUBDIVISIONS ENDORSEMENT
WC310303 A 05/20 WC310303A NEW YORK EXCESS MEDICALCOVERAGE ENDORSEMENT
WC310611 A 05/20 WC310611A NEW YORK EXCLUSION FORDESIGNATED OFFICERS ANDEMPLOYEES OF AMBULANCE DISTRICTSENDORSEMENT
WC310604 A 05/20 WC310604A NEW YORK FIRE DISTRICT LIABILITYEXCLUSION ENDORSEMENT FORCOUNTY OR TOWN POLICIES
WC310617 B 05/20 WC310617B NEW YORK FOREIGN VOLUNTARYCOMPENSATION AND EMPLOYERS’LIABILITY COVERAGE ENDORSEMENT
WC310308 01/00 WC 31 03 08 NEW YORK LIMIT OF LIABILITYENDORSEMENT
WC310407 10/17 WC 31 04 07
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
NEW YORK MERIT RATING REVISIONENDORSEMENT
WC310322 A 05/20 WC310322A NEW YORK OPTIONAL CLIENTEXCLUSION ENDORSEMENT
WC310320 A 05/20 WC310320A NEW YORK OPTIONAL PROFESSIONALEMPLOYER ORGANIZATION (PEO)ENDORSEMENT
WC310321 A 05/20 WC310321A NEW YORK OPTIONAL PROFESSIONALEMPLOYER ORGANIZATION (PEO)EXCLUSION ENDORSEMENT
WC310404 B 05/20 WC 31 04 04 B NEW YORK PENDING PAYROLLLIMITATION AND PREMIUMDIFFERENTIAL ENDORSEMENT
WC310317 A 05/20 WC310317A NEW YORK PROFESSIONAL EMPLOYERORGANIZATION (PEO) ENDORSEMENT
WC310318 A 05/20 WC310318A NEW YORK PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC310405 A 05/20 WC310405A NEW YORK SAFE PATIENT HANDLINGACT PROGRAM EXPLANATORYENDORSEMENT (FLAT CREDIT)
WC310406 A 05/20 WC310406A NEW YORK SAFE PATIENT HANDLINGACT PROGRAM EXPLANATORYENDORSEMENT (TIERED CREDIT)
WC310313 C 05/20 WC 31 03 13 C NEW YORK SOLE PROPRIETORS,PARTNERS AND MEMBERS OF LLC’S,PSLC’S AND RLLP’S COVERAGEENDORSEMENT
WC310316 C 05/20 WC310316C NEW YORK SOLE PROPRIETORS,PARTNERS AND MEMBERS OFLLC’S, PSLC’S, RLLP’S EXCLUSIONENDORSEMENT
WC310610 A 05/20 WC310610A NEW YORK VOLUNTEER AMBULANCEWORKERS’ BENEFIT LAW GROUPINSURANCE ENDORSEMENT
WC310608 A 05/20 WC310608A NEW YORK VOLUNTEER AMBULANCEWORKERS’ PREMIUM DISCOUNTENDORSEMENT
WC310607 A 05/20 WC310607A NEW YORK VOLUNTEER FIREFIGHTERS’BENEFIT LAW EXTENSION OFEMPLOYERS’ LIABILITY INSURANCEENDORSEMENT
WC310605 A 05/20 WC310605A NEW YORK VOLUNTEER FIREFIGHTERS’BENEFIT LAW GROUP INSURANCEENDORSEMENT
WC310606 A 05/20 WC310606A NEW YORK VOLUNTEER FIREFIGHTERS’PREMIUM DISCOUNT ENDORSEMENT
WC232 04/84 WC 31 03 11 NON/SUBJ EMP END [NY]WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUND
INSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC233 04/84 WC 31 03 12 NON-SUBJECT EXEC [NY]RR50 10/10 RR-50 NOTICE OF ELECTION OF
RETROSPECTIVE RATING PLANNYLR1 10/10 NYLR-1 NOTICE OF ELECTION OF
RETROSPECTIVE RATING PLAN - NEWYORK LARGE RISK RATING OPTION
WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TO
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
RR1 10/10 RR-1 NOTIFICATION OF COVERAGE - MULTI-STATE RETROSPECTIVE RATING PLAN
WC615 A 01/99 WC310616A NY PREF PROV ORG ENDWC616 A 01/99 WC 31 04 03 A NY PREF PROV ORG PREM ENDWC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDS
ACT COVERAGE ENDORSEMENTWC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITY
INSURANCEWC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERS
EXCLUSION ENDORSEMENTWC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC310618 A 05/20 WC 31 06 18 A POLICYHOLDER NOTICE OF RIGHT TO
APPEALWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC481 10/93 WC 00 05 15 RETROSPECTIVE PREMIUM
ENDORSEMENT - FLEXIBILITY OPTIONSWC414 12/91 WC 00 05 05 A RETROSPECTIVE PREMIUM
ENDORSEMENT - LONG TERMCONSTRUCTION PROJECT
WC417 12/91 WC 00 05 14 A RETROSPECTIVE PREMIUMENDORSEMENT - LONG-TERMCONSTRUCTION PROJECT - MULTIPLELINES
WC144 04/84 WC 00 05 10 RETROSPECTIVE PREMIUMENDORSEMENT - NON-RATABLECATASTROPHE ELEMENT ORSURCHARGE
WC412 12/91 WC 00 05 03 A RETROSPECTIVE PREMIUMENDORSEMENT - ONE YEAR PLAN
WC415 12/91 WC 00 05 12 A RETROSPECTIVE PREMIUMENDORSEMENT - ONE YEAR PLAN -MULTIPLE LINES
WC413 12/91 WC 00 05 04 A RETROSPECTIVE PREMIUMENDORSEMENT - THREE YEAR PLAN
WC416 12/91 WC 00 05 13 A
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RETROSPECTIVE PREMIUMENDORSEMENT - THREE YEAR PLAN -MULTIPLE LINES
WC650 04/84 WC000509 RETROSPECTIVE PREMIUMENDORSEMENT CHANGES
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC120 04/84 WC 00 03 09 RURAL ELECTRIFICATIONADMINISTRATION ENDORSEMENT
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC000420 12/02 WC 00 04 24 TERRORISM RISK INSURANCE ACTENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC407 04/91 WC 31 06 13 VOLUNTEER AMBULANCE WORKERS’BENEFIT LAW - EXTENSION OFEMPLOYERS’ LIABILITY INSURANCEENDORSEMENT
WC310002 B 05/20 WC310002B VOLUNTEER AMBULANCE WORKERS’BENEFIT LAW POLICY
WC310000 05/20 WC310000B VOLUNTEER FIREFIGHTERS’ BENEFITLAW POLICY
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
North CarolinaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC320304 01/09 WC 32 03 04 ALTERNATE EMPLOYER ENDORSEMENT
(EXCLUDING EMPLOYERS LIABILITYCOVERAGE)
WC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC320415 07/16 WC 32 04 15 ASSIGNED RISK ADJUSTMENT PROGRAM
ENDORSEMENTWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM
ENDORSEMENT
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC320418 07/16 WC 32 04 18 ASSIGNED RISK LOSS SENSITIVE RATINGPLAN ENDORSEMENT
WC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATINGPLAN ENDORSEMENT
WC320417 07/16 WC 32 04 17 ASSIGNED RISK LOSS SENSITIVE RATINGPLAN NOTIFICATION ENDORSEMENT
WC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATINGPLAN NOTIFICATION ENDORSEMENT
WC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT
WC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGEENDORSEMENT
WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC320601 B 04/20 WC320601B CANCELLATION AND NON-RENEWAL
ENDORSEMENTNCRB-ERM-14 10/16 NCRB-ERM-14 CONFIDENTIAL REQUEST FOR
OWNERSHIP INFORMATION(INTRASTATE RISK)
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC320302 2 11/08 WC 32 03 02 CONTROL INS PROG W/LARGEDEDUCTIBLE
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC103 04/84 WC 00 01 04 FEDERAL EMPLOYERS' LIABILITY ACTCOVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUMENDORSEMENT
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSION
ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC320301 D 07/18 WC 32 03 01 D NORTH CAROLINA AMENDEDCOVERAGE ENDORSEMENT
WC320303 11/08 WC 32 03 03 NORTH CAROLINA CONTROLLEDINSURANCE PROGRAM - AMENDATORYENDORSEMENT
WC320603 07/18 WC 32 06 03 NORTH CAROLINA NON-INSURANCEGOODS AND/OR SERVICESENDORSEMENT
WC320604 08/18 WC 32 06 04 NORTH CAROLINA NOTICE OFCANCELLATION OR MATERIAL CHANGETO DESIGNATED GOVERNMENTALENTITY ENDORSEMENT
WC320307 04/17 WC 32 03 07 NORTH CAROLINA PROFESSIONALEMPLOYER ORGANIZATION (PEO)CLIENT EXCLUSION ENDORSEMENT
WC320308 04/17 WC 32 03 08 NORTH CAROLINA PROFESSIONALEMPLOYER ORGANIZATION (PEO)CLIENT EXTENSION ENDORSEMENT
WC320305 04/17 WC 32 03 05 NORTH CAROLINA PROFESSIONALEMPLOYER ORGANIZATION (PEO)EXCLUSION ENDORSEMENT
WC320306 04/17 WC 32 03 06 NORTH CAROLINA PROFESSIONALEMPLOYER ORGANIZATION (PEO)EXTENSION ENDORSEMENT
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTNCDISC2 02/15 DISCLOSURE NO.2 POLICYHOLDER DISCLOSURE NOTICE OF
TERRORISM INSURANCE COVERAGENCDISC1 02/15 DISCLOSURE NO.1 POLICYHOLDER DISCLOSURE NOTICE OF
TERRORISM INSURANCE COVERAGEWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC320602 01/10 WC 32 06 02 PRO-RATA CANCELLATIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC414 12/91 WC 00 05 05 A RETROSPECTIVE PREMIUM
ENDORSEMENT - LONG TERMCONSTRUCTION PROJECT
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
North DakotaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT
WC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGEENDORSEMENT
WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC448 07/92 WC 00 01 11 MIGRANT AND SEASONALAGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 98 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RESIDUAL MARKET MULTIPLECOMPANY ENDORSEMENT
WC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—AVIATION
WC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—CHANGES
WC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—SHORT FORM
WC137 04/84 WC 00 05 03 RETROSPECTIVE PREMIUMENDORSEMENT - RATING OPTIONS V -ONE YEAR PLAN
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000501 04/84 WC 00 05 01 RETROSPECTIVE-1YR PLAN-OPTION I, II,III & IV
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
OhioWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC115 04/84 WC 00 03 04
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 99 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
INSURANCE COMPANY AS INSUREDENDORSEMENT
WC116 04/84 WC 00 03 05 JOINT VENTURE AS INSUREDENDORSEMENT
WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGEENDORSEMENT
WC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC448 07/92 WC 00 01 11 MIGRANT AND SEASONALAGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UP
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 100 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
CONSTRUCTION PROJECT—MULTIPLELINES
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
OklahomaWC112 04/84 WC 00 03 01 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC350602 D 09/16 WC 35 06 02 D BENEFITS DED ENDT (OK)
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC590 07/96 WC350404 CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT ENDORSEMENT
NC5000 D 08/19 NC-5000 D CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT PROGRAMWORKERS COMPENSATION PREMIUMCREDIT APPLICATION
WC336 01/87 WC 35 03 02 EMPLOYERS LIAB AM [OK]WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC534 12/93 WC350603 FRAUD WARNING END [OK]WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC350403 B 11/01 WC 35 04 03 B MERIT RATING END (OK)WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE IN
OWNERSHIPWC350601 F 02/14 WC 35 06 01 F OKLAHOMA CANCELLATION,
NONRENEWAL AND CHANGEENDORSEMENT
WC350604 08/99 WC 35 06 04 OKLAHOMA ELECTION OF COVNOTIFICATION ENDORSEMENT
WC350303 03/11 WC 35 03 03 OKLAHOMA EMPLOYERS LIABILITYINTENTIONAL TORT EXCLUSIONENDORSEMENT
FORM35-3 C 09/16 FORM 35-3C OKLAHOMA WORKERS COMPENSATIONMANDATORY OPTIONAL DEDUCTIBLEACCEPTANCE/REJECTION FORM
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGES
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—SHORT FORM
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
FORM35-4 A 07/06 FORM354A0706 WORKERS COMPENSATION DEDUCTIBLEACCEPTANCE/REJECTION FORM
WC350402 A 01/01 WC 35 04 02 A WORKERS COMPENSATION PREMIUMREDUCTION PROGRAM (WCPR)ENDORSEMENT
OregonWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM
ENDORSEMENTWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING
PLAN ENDORSEMENTWC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATING
PLAN NOTIFICATION ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC360601 E 01/08 WC 36 06 01 E CANCELATION END (OR)WC405 01/91 WC 36 04 02 CONT CLASS PRE ADJ (OR)WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTNC5000 D 08/19 NC-5000 D CONTRACTING CLASSIFICATION
PREMIUM ADJUSTMENT PROGRAMWORKERS COMPENSATION PREMIUMCREDIT APPLICATION
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUMENDORSEMENT
WC532 10/93 WC3604041093 GROUP SUPPL EXP [OR]WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC353 01/88 WC 36 04 01 MERIT RATING ENDT (OR)WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC360604 01/17 WC 36 06 04 OREGON AMENDATORY ENDORSEMENTWC360602 01/11 WC 36 06 02 OREGON CONFIDENTIALITY
ENDORSEMENTWC360603 01/11 WC 36 06 03 OREGON EMPLOYER PAID MEDICAL
CLAIMS ENDORSEMENTWC360404 A 05/17 WC 36 04 04 A OREGON GROUP SUPPLEMENTAL
EXPERIENCE RATING PLANENDORSEMENT
WC360306 01/02 WC 36 03 06 OREGON LIMITS OF LIABILITYENDORSEMENT
WC360406 10/01 WC 36 04 06
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 103 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
OREGON PREMIUM DUE DATEENDORSEMENT
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC541 01/94 WC 36 03 02 PILOT PROG MED BEN (OR)WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC162 04/84 WC 36 03 01 UNSAFE EQUIP EXCL [OR]WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION AND
EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
PennsylvaniaWC190 04/84 WC 37 03 01 (PA)CHURCH ENDWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC370404 C 05/17 WC 37 04 04 C CERT SAFETY COM END(PA)WC279 01/91 WC 37 04 02 CONST CLASS PREM (PA)WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC498 08/93 WC 37 04 03 DEDUCTIBLE ENDT [PA]WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC370604 10/99 WC 37 06 04 EMPLOYER ASSESSMENTENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC192 04/84 WC 37 03 03 EXCLUSION OF EMP (PA)WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM
ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC595 08/96 WC370405 MERIT RATING PLAN(PA)WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC346 A 08/95 WC 37 06 03 A NOT OF INC OF PREM (PA)WC434 04/84 WC 37 06 02 NOTICE (PA)WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENT
OF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC370109 01/05 WC 37 01 09 PENNSYLVANIA - NOTIFICATION
ENDORSEMENT OF PENDING LAWCHANGE TO TERRORISM RISKINSURANCE ACT OF 2002
WC370406 01/05 WC 37 04 06 PENNSYLVANIA - TERRORISM RISKINSURANCE ACT ENDORSEMENT
WC370401 01/17 WC 37 04 01 PENNSYLVANIA AUDITNONCOMPLIANCE CHARGEENDORSEMENT
WC370311 01/13 WC 37 03 11 PENNSYLVANIA MULTIPLECOORDINATED POLICY ENDORSEMENT
WC649 K 07/19 PCCPAP PENNSYLVANIA WORKERSCOMPENSATION PREMIUM CREDITAPPLICATION
WC191 04/84 WC 37 03 02 POLICE/FIRE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC193 04/84 WC 37 03 04 PRINCIPAL AS ADDITIONAL INSUREDWC194 04/84 WC 37 03 05 PROF ASSOC ACT EN [PA]WC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC195 04/84 WC 37 03 06 REAL ESTATE MGMT END (PA)WC196 04/84 WC 37 03 07 RELIGIOUS INS [PA]WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC414 12/91 WC 00 05 05 A RETROSPECTIVE PREMIUM
ENDORSEMENT - LONG TERMCONSTRUCTION PROJECT
WC417 12/91 WC 00 05 14 A RETROSPECTIVE PREMIUMENDORSEMENT - LONG-TERMCONSTRUCTION PROJECT - MULTIPLELINES
WC144 04/84 WC 00 05 10 RETROSPECTIVE PREMIUMENDORSEMENT - NON-RATABLECATASTROPHE ELEMENT ORSURCHARGE
WC412 12/91 WC 00 05 03 A RETROSPECTIVE PREMIUMENDORSEMENT - ONE YEAR PLAN
WC415 12/91 WC 00 05 12 A RETROSPECTIVE PREMIUMENDORSEMENT - ONE YEAR PLAN -MULTIPLE LINES
WC413 12/91 WC 00 05 04 A RETROSPECTIVE PREMIUMENDORSEMENT - THREE YEAR PLAN
WC416 12/91 WC 00 05 13 A RETROSPECTIVE PREMIUMENDORSEMENT - THREE YEAR PLAN -MULTIPLE LINES
WC650 04/84 WC000509 RETROSPECTIVE PREMIUMENDORSEMENT CHANGES
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC120 04/84 WC 00 03 09 RURAL ELECTRIFICATIONADMINISTRATION ENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC189 04/84 WC 37 06 01 SPECIAL END (PA)WC197 04/84 WC 37 03 08 SPOUSE OF INS END (PA)
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC198 B 03/86 WC 37 03 09 STATUTORY EMPLOYER (PA)WC000420 12/02 WC 00 04 24 TERRORISM RISK INSURANCE ACT
ENDORSEMENTWC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION AND
EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
Rhode IslandWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR
OWNERSHIP INFORMATIONWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC163 04/84 WC 38 06 01 DIRECT LIAB ST [RI]WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUMENDORSEMENT
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 108 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSION
ENDORSEMENTWC118 04/84 WC 00 03 07 MEDICAL BENEFITS REIMBURSEMENT
ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 109 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC496 06/93 WC 38 06 02 SAFETY INSP END [RI]WC380401 B 01/15 WC 38 04 01 B SHORT RATE CANCELLATION
ENDORSEMENTWC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,
OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
South CarolinaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEFORM39-1 A 09/14 FORM39-1A APPLICATION FOR DRUG - AND
ALCOHOL-FREE WORKPLACE PREMIUMCREDIT PROGRAM
WC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAMENDORSEMENT
WC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATINGPLAN ENDORSEMENT
WC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATINGPLAN NOTIFICATION ENDORSEMENT
WC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT
WC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGEENDORSEMENT
WC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGEENDORSEMENT
WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT(New) WC000421 E 01/21 WC000421E
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 110 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSION
ENDORSEMENTWC118 04/84 WC 00 03 07 MEDICAL BENEFITS REIMBURSEMENT
ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 111 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 112 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
South DakotaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM
ENDORSEMENTWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING
PLAN ENDORSEMENTWC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATING
PLAN NOTIFICATION ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC400602 07/90 WC 40 06 02 BENEFITS DEDUCTIBLE ENDORSEMENTWC400605 B 04/06 WC 40 06 05 B CANCELLATION AND NONRENEWAL
ENDORSEMENT(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIED
ACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 113 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC116 04/84 WC 00 03 05 JOINT VENTURE AS INSUREDENDORSEMENT
WC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSIONENDORSEMENT
WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGEENDORSEMENT
WC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC568 01/94 WC400603 MANAGED CARE END [SD]WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC600 09/96 WC4006040996 MED BEN DED END (SD)WC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSION
ENDORSEMENTWC118 04/84 WC 00 03 07 MEDICAL BENEFITS REIMBURSEMENT
ENDORSEMENTWC457 A 01/96 WC 40 04 01 A MERIT RATING END (SD)WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 1
WC267 07/91 WC 00 04 10 PREMIUM DETERMINATIONENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 114 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
TennesseeWC410403 07/12 WC 41 04 03 (TWCIP) LARGE ACCOUNT INCURRED
LOSS PREMIUM ADJUSTMENT PLAN(TAIL PLAN) - ENDORSEMENT ANDNOTICE
WC410404 07/12 WC 41 04 04 (TWCIP) LARGE ACCOUNT INCURREDLOSS PREMIUM ADJUSTMENT PLAN(TAIL PLAN) - RATING ENDORSEMENT
WC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 115 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC410401 A 01/08 WC 41 04 01 A ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC410301 01/09 WC 41 03 01 LIMITED OTHER STATES ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 116 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC410408 03/17 WC 41 04 08 TENNESSEE ASSIGNED RISKADJUSTMENT PROGRAM ENDORSEMENT
WC410402 08/03 WC 41 04 02 TENNESSEE PENDING LOSS COST ANDASSIGNED RISK RATE ENDORSEMENT
WC410405 07/15 WC 41 04 05 TENNESSEE SMALL EMPLOYER PLANENDORSEMENT
WC410406 07/15 WC 41 04 06 TENNESSEE SPECIAL RISK PLANENDORSEMENT
WC410407 07/15 WC 41 04 07 TENNESSEE TABULAR SURCHARGEENDORSEMENT
WC410601 A 09/12 WC 41 06 01 A TENNESSEE WORKERS COMPENSATIONINSURANCE PLAN (TWCIP)REHABILITATION AND TABULARSURCHARGE REDUCTION INCENTIVEPROGRAM PREMIUM ENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
FORM41-3 01/07 FORM4130107 WORKERS' COMPENSATION INSURANCEPLAN - COST REDUCTION SEMINARINCENTIVE PLAN PREMIUM CREDITFORM
FORM41-1 01/07 FORM4110107 WORKERS COMPENSATION INSURANCEPLAN - SMALL EMPLOYER PLAN FORM
FORM41-2 01/07 FORM4120107 WORKERS' COMPENSATION INSURANCEPLAN - SPECIAL RISK PLAN FORM
TexasWC420604 B 01/00 WC 42 06 04 B ACCIDENT/AGGREGATE DEDUCTIBLE
ENDORSEMENTWC548 A 01/02 ERM411 ACCIDENTS INVOLVING TWO OR MORE
PERSONSWC420603 B 01/00 WC 42 06 03 B AGGREGATE DED END (TX)WC126 04/84 WC 00 04 01 AIRCRAFT PREMIUM ENDORSEMENTWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC112 04/84 WC 00 03 01 ALTERNATE EMPLOYER ENDORSEMENTWC564 A 03/97 WC420402A0397 ANNIV RATING DATE (TX)WC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC362 01/90 WC 00 04 12
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
DNE1 A 06/14 DNE-1A DEDUCTIBLE NOTICE OF ELECTIONWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC420406 D 06/14 WC 42 04 06 D EMPLOYEE PROVIDER/CLIENTCOMPANY ENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC420305 A 01/00 WC 42 03 05 A EXEMPT EMPL COV END(TX)WC275 A 03/97 WC 42 04 03 A EXPERIENCE RATING (TX)WC551 05/94 ERM12 EXPERIENCE RATING FORMWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC103 04/84 WC 00 01 04 FEDERAL EMPLOYERS' LIABILITY ACT
COVERAGE ENDORSEMENTWC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM
ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC601 01/97 WC4203080197 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
PREMIUM DETERMINATIONENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLECOMPANY ENDORSEMENT
WC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—AVIATION
WC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—CHANGES
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC120 04/84 WC 00 03 09 RURAL ELECTRIFICATIONADMINISTRATION ENDORSEMENT
WC602 01/97 WC4203100197 SOLE PROPRIETORSWC420407 03/02 WC 42 04 07 TEXAS - AUDIT PREMIUM AND
RETROSPECTIVE PREMIUMENDORSEMENT
WC420602 A 06/14 WC 42 06 02 A TEXAS ACCIDENT DEDUCTIBLEENDORSEMENT
WC420315 07/15 WC 42 03 15 TEXAS ADVANCE NOTICE OFCANCELLATION TO THE PROFESSIONALEMPLOYER ORGANIZATION (PEO)
(New) WC420301 J 06/20 WC420301J TEXAS AMENDATORY ENDORSEMENTWC420605 06/14 WC 42 06 05 TEXAS CLAIM DEDUCTIBLE
ENDORSEMENTWC420312 07/15 WC 42 03 12 TEXAS COVERED EMPLOYEE
EXCLUSION ENDORSEMENT FOR POLICYCOVERING DIRECT EMPLOYEES OF ACLIENT
WC420404 A 06/14 WC 42 04 04 A
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
TEXAS GROUP PURCHASE OFWORKERS COMPENSATION INSURANCEENDORSEMENT
WC420408 A 06/14 WC 42 04 08 A TEXAS HEALTH CARE NETWORKENDORSEMENT
WC420606 06/14 WC 42 06 06 TEXAS MEDICAL BENEFITS DEDUCTIBLEENDORSEMENT
WC420601 01/94 WC 42 06 01 TEXAS NOTICE OF MATERIAL CHANGEENDORSEMENT
WC420316 07/15 WC 42 03 16 TEXAS PROFESSIONAL EMPLOYERORGANIZATION (PEO) CLIENTENDORSEMENT
WC420311 07/15 WC 42 03 11 TEXAS PROFESSIONAL EMPLOYERORGANIZATION (PEO) ENDORSEMENT
WC420314 07/15 WC 42 03 14 TEXAS PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXECUTIVEEMPLOYEE EXCLUSION ENDORSEMENT
WC420313 07/15 WC 42 03 13 TEXAS PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXECUTIVEEMPLOYEE INCLUSION ENDORSEMENT
WC420511 06/11 WC 42 05 11 TEXAS RETROSPECTIVE PREMIUMENDORSEMENT SHORT FORM
WC420505 C 01/19 WC 42 05 05 C TEXAS RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT LONG-TERMCONSTRUCTION PROJECT
WC420514 C 01/19 WC 42 05 14 C TEXAS RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT LONG-TERMCONSTRUCTION PROJECT - MULTIPLELINES
WC420510 B 01/15 WC 42 05 10 B TEXAS RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENTNONRATABLE CATASTROPHE ELEMENTOR SURCHARGE
WC420503 D 01/19 WC 42 05 03 D TEXAS RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC420512 D 01/19 WC 42 05 12 D TEXAS RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC420504 D 01/19 WC 42 05 04 D TEXAS RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC420513 D 01/19 WC 42 05 13 D TEXAS RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC420303 B 01/00 WC 42 03 03 B VOL WORKERS COV ENDT (TX)WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION AND
EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC420304 B 06/14 WC 42 03 04 B WAIVER OF OUR RIGHT TO RECOVERFROM OTHERS ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
UtahWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATE
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT
WC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGEENDORSEMENT
WC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGEENDORSEMENT
WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR
OWNERSHIP INFORMATIONWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUMENDORSEMENT
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC430602 07/02 WC 43 06 02 UTAH CANCELLATION ENDORSEMENTWC430303 01/00 WC 43 03 03 UTAH EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC430304 01/00 WC 43 03 04 UTAH EMPLOYEE LEASING COMPANY
EXCLUSION ENDORSEMENTWC430302 A 05/17 WC 43 03 02 A UTAH EMPLOYEE LEASING
ENDORSEMENTWC430305 07/00 WC 43 03 05 UTAH WAIVER OF SUBROGATION
ENDORSEMENTWC490 01/93 WC 43 06 01 UTAH WORKPLACE SAFETY PROGRAM
ENDORSEMENTWC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION AND
EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
VermontWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM
ENDORSEMENTWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING
PLAN ENDORSEMENTWC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATING
PLAN NOTIFICATION ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC440603 07/08 WC 44 06 03 BENEFITS DEDUCT ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION
ENDORSEMENTWC165 04/84 WC 44 06 01 LAW END [VT]WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSION
ENDORSEMENTWC118 04/84 WC 00 03 07 MEDICAL BENEFITS REIMBURSEMENT
ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC440602 B 07/14 WC 44 06 02 B VERMONT CANCELLATION ANDNONRENEWAL ENDORSEMENT
WC440401 04/03 WC 44 04 01 VERMONT WORKERS COMPENSATIONINSURANCE PLAN MERIT RATINGENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
VirginiaWC173 A 10/85 WC 45 06 01 ADDITIONAL BENEFITS ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM
ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC593 05/96 WC450603 BENEFITS DED END (VA)WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR
OWNERSHIP INFORMATIONWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC450604 01/97 WC 45 06 04 CONTRACTING CLASSIFICATION
PREMIUM ADJUSTMENT ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUMENDORSEMENT
WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSION
ENDORSEMENTWC118 04/84 WC 00 03 07 MEDICAL BENEFITS REIMBURSEMENT
ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 127 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC448 07/92 WC 00 01 11 MIGRANT AND SEASONALAGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UP
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 128 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
CONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC489 07/93 WC 45 06 02 VIRGINIA AMENDATORYENDORSEMENT
WC450303 01/01 WC 45 03 03 VIRGINIA CLIENT COMPANYENDORSEMENT
WC450304 01/01 WC 45 03 04 VIRGINIA CLIENT COMPANY EXCLUSIONENDORSEMENT
FORM453 F 04/20 FORM 45-3F VIRGINIA CONTRACTINGCLASSIFICATION PREMIUMADJUSTMENT PROGRAM (CCPAP)WORKERS COMPENSATION PREMIUMCREDIT APPLICATION
WC450301 01/01 WC 45 03 01 VIRGINIA PEO ENDORSEMENTWC450302 01/01 WC 45 03 02 VIRGINIA PEO EXCLUSION
ENDORSEMENTWC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION AND
EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
WashingtonWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 129 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC448 07/92 WC 00 01 11 MIGRANT AND SEASONALAGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 130 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
West VirginiaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM
ENDORSEMENTWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING
PLAN ENDORSEMENTWC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATING
PLAN NOTIFICATION ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE
ENDORSEMENTWC470601 01/06 WC 47 06 01 CANCELLATION ENDORSEMENT
(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT
ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION
WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT
WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION
FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND
SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT
COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
MIGRANT AND SEASONALAGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC470306 08/09 WC 47 03 06 MULTIPLE COORDINATED POLICYENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE
ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC470304 08/09 WC 47 03 04 PROFESSIONAL EMPLOYERORGANIZATION CLIENT COMPANYEXCLUSION ENDORSEMENT
WC470305 08/09 WC 47 03 05 PROFESSIONAL EMPLOYERORGANIZATION EXCLUSIONENDORSEMENT
WC470303 08/09 WC 47 03 03 PROFESSIONAL EMPLOYERORGANIZATION EXTENSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT
WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT
(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
WC470301 A 07/08 WC 47 03 01 A WEST VIRGINIA EMPLOYERS LIABILITYINSURANCE DELIBERATE INTENTIONEXCLUSION ENDORSEMENT
WC470314 B 07/11 WC 47 03 14 B WEST VIRGINIA WORKERSCOMPENSATION AND EMPLOYERSLIABILITY COVERAGE FOR DOMESTICSERVICE EMPLOYEES ENDORSEMENT
WC470302 07/06 WC 47 03 02 WEST VIRGINIA WORKERSCOMPENSATION INSURANCE RECOVERYFROM OTHERS ENDORSEMENT
WisconsinWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC607 07/97 WC4804010797 CONTRACTORS PREMIUM ADJUSTMENT
PROGRAMWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENT
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,
AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT
WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT
WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT
WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT
WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT
WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT
WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT
WC480603 B 01/01 WC 48 06 03 B FOREIGN COVERAGE END [WI]WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM
ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC480601 C 04/01 WC 48 06 01 C LAW ENDORSEMENT (WI)WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC480301 C 12/07 WC 48 03 01 C LIMITED OTHER STATES INSURANCE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC480319 05/18 WC 48 03 19 NOTICE OF CANCELLATION ORMATERIAL COVERAGE CHANGE TODESIGNATED GOVERNMENTAL ENTITY
WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
POLICY INFORMATION PAGEENDORSEMENT
WC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
ORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC480517 B 01/19 WC 48 05 17 B RETROSPECTIVE PREMIUM
ENDORSEMENT - LARGE RISKALTERNATIVE RATING OPTION
WC480507 B 01/19 WC 48 05 07 B RETROSPECTIVE PREMIUMENDORSEMENT LARGE RISKALTERNATIVE RATING OPTION
WC480506 B 01/19 WC 48 05 06 B RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT - LARGE RISKALTERNATIVE RATING OPTION
WC480502 A 01/19 WC 48 05 02 A RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT - LARGE RISKALTERNATIVE RATING OPTION - PLANTYPE
WC480512 07/11 WC 48 05 12 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT - LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC480503 A 01/19 WC 48 05 03 A RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT - LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC480508 B 01/19 WC 48 05 08 B RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT - LARGE RISKALTERNATIVE RATING OPTION (LRARO)
WC480510 B 01/19 WC 48 05 10 B RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT - WISCONSINLARGE RISK ALTERNATIVE RATINGOPTION (LRARO)
WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D
Workers' CompensationPolicy Forms and Endorsements
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UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC178 04/84 WC 48 06 02 RURAL ELECT COOP (WI)WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICE
ENDORSEMENTWC653 A 07/13 WC 48 05 01 A SCHEDULE OF VARIABILITY TO
ENDORSEMENT WC 48 05 01WC654 09/11 WC480506 SCHEDULE OF VARIABILITY TO
ENDORSEMENT WC 48 05 06WC655 A 01/15 WC480512A SCHEDULE OF VARIABILITY TO
ENDORSEMENT WC 48 05 12WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,
OFFICERS AND OTHERS COVERAGEENDORSEMENT
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT
WC480606 B 01/02 WC 48 06 06 B WISCONSIN CANCELLATION ANDNONRENEWAL ENDORSEMENT
WC480605 06/01 WC 48 06 05 WISCONSIN CHANGE OF INSURANCECARRIER NAME ENDORSEMENT
WC480316 04/08 WC 48 03 16 WISCONSIN EMPLOYEE LEASINGCOMPANY CLIENT TERMINATIONENDORSEMENT—MASTER POLICY
WC480314 04/08 WC 48 03 14 WISCONSIN EMPLOYEE LEASINGCOMPANY ENDORSEMENT—MASTERPOLICY
WC480315 04/08 WC 48 03 15 WISCONSIN EMPLOYEE LEASINGCOMPANY ENDORSEMENT—MULTIPLECOORDINATED POLICY (MCP)
WC480304 07/16 WC 48 03 04 WISCONSIN REAL ESTATESALESPERSONS ENDORSEMENT
WC480514 02/12 WC 48 05 14 WISCONSIN RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT - LARGERISK ALTERNATIVE RATING OPTION
WC480519 D 01/19 WC 48 05 19 D WISCONSIN RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT - LARGERISK ALTERNATIVE RATING OPTION(PAID LOSS)
WC623 11/96 WC4806041196 WISCONSIN WAIVER OF SOVEREIGNWC480302 A 01/13 WC 48 03 02 A WISCONSIN WORK-STUDY COVERAGE
ENDORSEMENTWC480520 A 01/19 WC 48 05 20 A WISCONSIN—RETROSPECTIVE RATING
PLAN PREMIUM ENDORSEMENT - LARGERISK ALTERNATIVE RATING OPTION(LRARO)
WC606 03/97 WC4803020397
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 136 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
WORK-STUDY COVERAGEENDORSEMENT
WyomingWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC467 07/92 WC 49 03 01 AMENDATORY END [WY]WC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM
DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE
ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING
MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE
ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT
ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT
EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE
ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION
FACTOR ENDORSEMENTWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED
ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE
ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'
COMPENSATION ACT COVERAGEENDORSEMENT
WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT
WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT
WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT
WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT
WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT
WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT
WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION
ENDORSEMENT - FORMER SELF-INSURERS 2
WC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC000320 B 01/06 WC 00 03 20 B
Workers' CompensationPolicy Forms and Endorsements
(New)Denotes change.PAGE WC 137 of 137 WOLTERS KLUWER Customer Support: 800-382-2424
UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE
PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT
WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE
COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—
AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—
CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—
SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN
PREMIUM ENDORSEMENT ONE-YEARPLAN
WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES
WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN
WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES
WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT
WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES
WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT
WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT