1. Forms
  2. WC
  3. WC-89-06-00

What it does

WC 89 06 00 B (Ed. 7-01) is the standard vehicle for changing the Information Page after the policy is issued. The form lists each item that can be changed, each with its own sub-number for electronic policy reporting, and the carrier checks the item being changed and states the new wording. "All other terms and conditions of this policy remain unchanged."

Items it can change

  • Insured's name (WC 89 06 01), policy number (06 02), effective date (06 03), expiration date (06 04), mailing address (06 05), legal status (06 10).
  • Experience modification (WC 89 04 06), producer's name (06 07), change in workplace (06 08).
  • Item 3.A. states (06 11), Item 3.B. limits (06 12), Item 3.C. states (06 13), Item 3.D. endorsement numbers (06 14).
  • Item 4 class, rate and other changes (WC 89 04 15), with a schedule for classification code, premium basis, estimated remuneration, rate per $100 and estimated premium, plus minimum and deposit premium; interim adjustment of premium (04 16).
  • Carrier servicing office, interstate/intrastate risk ID number, carrier number, and issuing agency or producer office address.

Who needs it

Any insured whose operations change during the term: a new state of operation, a name change or new legal entity, a reclassification after an inspection, a revised experience modification, or a request for higher employers liability limits to satisfy an umbrella or contract.

Quoting and selling notes

  • Adding a state to Item 3.A. as soon as the insured hires or sends employees there gives full Part One coverage; relying on Item 3.C. leaves only the Other States reimbursement mechanism and, for work existing at inception, a thirty-day notice requirement.
  • A change in legal entity or ownership can also affect the experience modification. Pair a name or entity change with the ownership reporting required by WC 00 04 14.
  • Some bureau states publish their own versions (Minnesota uses a WC 22 06 series of Policy Information Page endorsements).

Related forms

Information Page WC 00 00 01; policy WC 00 00 00; ownership change WC 00 04 14.