1. Forms
2. WC
3. WC-00-00-01

Workers Compensation and Employers Liability Insurance Policy Information Page (WC 00 00 01)

The WC 00 00 01 A - Workers Compensation and Employers Liability Insurance Policy Information Page serves as the declarations page for a workers' compensation and employers' liability insurance policy. It is a critical component of the policy, providing a snapshot of the essential details agreed upon by the insured and the insurer. This form personalizes the standard policy (WC 00 00 00) by outlining the specific coverage terms, limits, and other key data relevant to the individual insured. The National Council on Compensation Insurance, Inc. (NCCI) establishes rules for how information is presented on this page to ensure consistency for state and NCCI reporting requirements. While the sequence of Items 1 through 4 on the Information Page generally cannot be changed (with limited exceptions), the format of each item may be rearranged where allowed.

Classes of Business It Applies To

This form is applicable to virtually any class of business that is required by state law to carry workers' compensation insurance. Since workers' compensation laws exist in all states, this form is used across a vast spectrum of industries. Examples include, but are not limited to:

• Construction: A general contractor or a subcontractor would have this page detailing their various job classifications (e.g., carpentry, plumbing, electrical) and the states where they operate.
• Manufacturing: A factory producing goods would list its employee classifications (e.g., machine operators, assembly line workers, supervisors) and corresponding rates.
• Retail: A department store would use this form to show coverage for its sales staff, stockroom employees, and office personnel.
• Healthcare: Hospitals and clinics would detail classifications for nurses, administrative staff, and maintenance workers.
• Transportation: A trucking company would list drivers, mechanics, and dispatchers.
• Professional Services: An accounting firm or law office would have this page, though their risk profiles and classifications would differ significantly from more physically demanding industries.
• Temporary Staffing Agencies: These businesses have a particular need for accurate classifications and may utilize endorsements like the Alternate Employer Endorsement (WC 00 03 01 A), which would be referenced on this Information Page.

Essentially, any employer with employees who could suffer a work-related injury or occupational disease will have this form as part of their workers' compensation policy.

Special Considerations

Several special considerations are important when dealing with the WC 00 00 01 A:

• Accuracy is Paramount: All information, especially the insured's name, entity type (e.g., individual, partnership, corporation), FEIN, locations, employee classifications, and estimated payrolls, must be precise. Errors can lead to coverage disputes, incorrect premium calculations, and potential penalties. The premium information is subject to verification and change by audit.
• State-Specific Information (Item 3.A): This section lists the states where Workers' Compensation Insurance (Part One) applies. It's crucial to ensure all states where the insured has operations or employees are correctly listed. If no states are to be listed in rare circumstances, "NONE" should be entered to prevent confusion.
• Employers Liability Limits (Item 3.B): This section specifies the limits for Employers Liability Insurance (Part Two), typically with separate limits for Bodily Injury by Accident (per accident), Bodily Injury by Disease (policy limit), and Bodily Injury by Disease (each employee). These limits should be reviewed for adequacy based on the insured's potential exposure.
• Other States Insurance (Item 3.C): This section lists states where coverage may apply if the insured begins work there during the policy period, provided the insurer is notified. However, this is not automatic coverage for all states and has specific conditions.
• Endorsements (Item 3.D): All endorsements attached to the policy, which modify its terms, must be listed here. This could include endorsements for federal acts (e.g., Longshore and Harbor Workers' Compensation Act Coverage Endorsement WC 00 01 06 A), voluntary compensation, or waivers of subrogation.
• Monopolistic States: For work in monopolistic states (North Dakota, Ohio, Washington, Wyoming), employers typically secure workers' compensation directly from the state fund. However, employers' liability coverage for these states might be provided via an endorsement (e.g., WC 00 03 03 C) and noted on the Information Page.
• Policy Number: The policy number must be unique to the company, not exceed 18 alphanumeric digits, and remain constant during the policy period. It must appear on all endorsements and policy-related correspondence.

Real-world example: A contractor based in Pennsylvania wins a bid for a project in Maryland. If Maryland is not listed in Item 3.A. of their Information Page, they must immediately contact their agent to add Maryland to ensure coverage for employees working on the new project. Simply having "Other States Insurance" may not be sufficient without proper notification and underwriting.

Key Information for Agents and Underwriters

The WC 00 00 01 A is a cornerstone document for both agents and underwriters:

• Risk Assessment: The detailed information on employee classifications, payroll, and locations provides a primary basis for assessing the insured's risk profile. Underwriters scrutinize this to understand the nature and extent of potential hazards.
• Pricing and Premium Calculation: The classifications, rates, and estimated annual remuneration listed in Item 4 are fundamental to calculating the estimated annual premium. This section also includes the minimum premium and any expense constants. The final premium is subject to audit based on actual payrolls.
• Coverage Verification: Agents use this page to confirm that the policy is structured correctly to meet the client's needs and legal obligations, including correct states and limits.
• Identifying Coverage Gaps: By reviewing the listed states, classifications, and endorsements, agents and underwriters can identify potential gaps. For instance, if a business engages in maritime employment but lacks a Longshore and Harbor Workers' Compensation Act Coverage Endorsement (WC 00 01 06 A), this is a significant gap.
• Underwriting Guidelines: The NCCI provides rules on how information should be presented, ensuring consistency. Underwriters rely on this standardized format for efficient review and to ensure compliance with company and regulatory guidelines. For example, the exact legal name of the insured and their Federal Employer Identification Number (FEIN) must be correctly shown.
• Endorsement Management: Ensuring all applicable endorsements are correctly listed and attached is crucial. For example, if an insured requires coverage under the Defense Base Act, the WC 00 01 01 A endorsement must be listed.
• Audit Preparedness: The information on this page sets the stage for the year-end premium audit. Agents should counsel clients to maintain accurate payroll records corresponding to the classifications listed.

Real-world example for underwriters: An underwriter reviewing an application for a new construction business would pay close attention to Item 4. If the payroll for high-risk classifications like roofing seems unusually low compared to the stated number of employees or scope of operations, it could be a red flag for potential misclassification or underestimation of exposure, prompting further investigation before binding coverage.