Assigned Risk/Application Tips
You can fill it out now or fill it out later. Sending an incomplete app can VOID your effective date. So, we encourage you to fill out the whole thing the first time. There are no shortcuts for assigned risk apps! Here are some tips to help...
To complete Indiana assigned risk applications, you may:
complete an application online from the NCCI website at www.ncci.com. Agents completed about 97% of applications online, and we encourage you to use the online method. You will be using the RMAPS Online Application Service. [Exception: Some PEOs must use mail-in forms only. Please contact the ICRB Analyst with the names of the clients so we can match them to the PEO.] You will need an NCCI ID. To get one, call 800-NCCI-123, or
complete and mail (not fax) the ACORD 133 Workers Compensation Insurance Plan Assigned Risk section and ACORD 130 Workers Compensation Application. To get ACORD Forms, call 1-800-444-3341 or visit www.acord.com.
Note: We do not process phone-in or faxed applications.
Good to know: Check out the NCCI RMAPS Online Application Service—Webinar. It guides you through the basics of submitting an application online.
"Must Have" Items
Along with the appropriate deposit premium, we require at least ten things to be completed before we start processing the application. If you submit an incomplete application, you could lose your requested effective date, which may result in a lapse of coverage. We need all remaining information on the applications as well prior to binding coverage. Here are the "must have" items:
APPLICANT NAME: Legal name(s) of the employer.
MAILING ADDRESS: Where to mail the policy and other information to the employer.
LEGAL STATUS: Check the appropriate box or describe the employer; e.g. sole proprietorship, partnership, limited liability corporation (LLC), corporation, joint venture, trust, association, etc. Note: A husband and wife cannot both be a sole proprietor for one business. Only one of them is the sole proprietor. Check if perhaps the business is a partnership.
FEDERAL EMPLOYER ID NUMBER: The "EIN" or Employer Identification Number assigned by the Internal Revenue Service (www.irs.gov). A sole proprietor with no employees may provide a social security number. If a request for an EIN is pending issuance by the IRS, please provide proof of request.
LOCATIONS: The physical address where the employer is conducting business. Also list other locations where you desire coverage. If the location is a rural route, please also include driving instructions. If you can't give an address, please explain why.
POLICY INFORMATION: a. Part 1 - Workers Compensation (States): List each state in which the employer conducts business and where you desire coverage. Note: Coverage is only available in certain states through the National Pool. b. Proposed Effective Date: Start date for coverage.
RATING INFORMATION: Needed to calculate total estimated annual premium. Complete a row for each location by state.
- Location: The address where you desire coverage. Note: Also list locations for known or anticipated operations in additional states where you desire coverage.
- Class Code: The classification code(s) that best describes the type of business according to Basic Manual rules.
- List the number of workers for each class code.
- Remuneration: Total annual payroll or other remuneration for each class.
INDIVIDUALS INCLUDED/EXCLUDED: The name and title of each corporate officer, partner, LLC member, or sole proprietor. Also, provide the percent of ownership, duties, and whether or not each individual will be covered. Notes: In Indiana, an executive officer of a for-profit corporation is included, but may elect to be excluded. An executive officer of a municipal corporation, other governmental subdivision, or of a charitable, religious, educational, or other nonprofit corporation may be covered by specifically including the person in the insurance policy. A sole proprietor, partner, or LLC member may elect to be covered. If so, complete the State Form 36097 "Notice for Worker's Compensation and Occupational Diseases Coverage" which is commonly called the sole proprietor or partner election form. For other employees that may be excluded or included, please call us.
NATURE OF THE BUSINESS/DESCRIPTION OF OPERATIONS: Include enough detail to ensure proper classification of the business. For example, operations of a trucker may not be described simply as "Trucking: NOC," but may be explained as "employer delivers goods by truck on a contract basis to clients throughout the midwest."
APPLICANT'S SIGNATURE: The owner or an officer must sign the application.
Please make check payable to ICRB. If mailing application, all checks, including premium financed checks, must be sent with the application.
The chart below will help you determine the deposit premium. You can find the full set of rules in the Basic Manual green pages, or the Assigned Risk Supplement to the Basic Manual.
NOTE: If premium is greater than $250,000, please see LSRP rules at bottom of this tips page.
Estimated Annual Premium Payment Basis Minimum Initial Additional PaymentsUnder $2,500Annual100%NoneAt Least $2,500Semi-Annual75%OneAt Least $5,000Quarterly50%ThreeAt Least $25,000Monthly25%Eight
- 12:01 a.m. on date following receipt of a valid application.
- expiration date of existing coverage, or
- a date the applicant requests.
Conditions to bind:
The Bureau can only bind coverage after:
- all application information is complete, and
- correct deposit premium is deposited in the bank.
Once these conditions are met, the Indiana WCIP rules permit us to bind coverage the day after the U.S. Postal Service (USPS) postmark (NO METERED MAIL!). To meet today's business practice of using overnight delivery service, we also will bind coverage the day after the courier pick-up date. However, we must have proof of the pick-up date from the courier. Most overnight envelopes do not provide sufficient proof so you need to get a log statement from the courier.
If no postmark or proof of pick-up:
If an envelope has no postmark (remember, metered mail does not have a postmark!), or the postmark is unreadable, or if there is no proof of an overnight delivery pick-up date, then we will bind coverage the day after the bank processes the deposit check. Under this scenario, the binder date is dependent upon the days that could pass while the courier is delivering the envelope and the days that could pass for the bank to open its mail, enter application header information, and deposit the check. This could easily reach 5-10 days.
Who is the servicing carrier?
We use several insurance companies to actually write the assigned risk policies. They are called the servicing carriers. We will know which carrier is assigned to an employer once the binder is issued, not before. So, if there is missing information on the application or the deposit amount is wrong, we cannot bind coverage and we will not know which servicing carrier will be picked by our assignment system.
Do we have...Postmark or Proof of Pick-up?
YES: Bind day after postmark or proof of pick-up.
NO: Bind day after bank deposits check.
Guide to Premium
Apply the experience modification, if applicable, a 25% surcharge is applicable to the premium in excess of $2,500 of the standard premium. Apply terrorism rate of $0.02 and catastrophe (other than Certified Acts of Terrorism) rate of $0.01 to all payroll. The servicing carrier will separately bill the insured for a nominal Indiana Second Injury Fund surcharge after the policy is issued.
Sole proprietors, partners, LLC members, and officers of charitable, religious, educational or nonprofit corporations are not automatically covered under Indiana law, but they may elect. For sole proprietors, partners, and LLC members who are electing coverage, please attach State Form 36097, Notice For Workers Compensation and Occupational Diseases Coverage (79). Remember to include their payroll. Failure to file the appropriate forms for election or rejection status in acordance with State laws may result in additional premium being charged and collected by the Plan Administrator or the assigned carrier.
Corporate officers, except those mentioned above, are included, but may elect to exclude themselves.
Refer to the Workers Compensation Board of Indiana for the most current rules and forms.
Note: This information applies only to Indiana law. If additional states are to be covered, additional action may be necessary under applicable state law.
- Regular Mail: NCCI—Indiana, Attn: Treasury Department, PO Box 3045, Boca Raton, FL 33431
- Overnight Delivery: NCCI—Indiana, Attn: Treasury Department, 901 Peninsula Corporate Circle, Boca Raton, FL 33487-1362
Temporary Service or Employee Leasing?
Before completing applications, first decide if the employer is involved in a temporary help service or an employee leasing arrangement (PEO). See the definitions below to help you decide. If you are not sure, please call us.
The Basic Manual, Indiana Assigned Risk Special Rules (green pages), does a good job of defining employee leasing arrangements between the client (lessee), and the labor contractor (lessor) also known as the employee leasing company.
RULE IX. 1. Definitions
a. Employee leasing arrangement shall mean an arrangement, under contract or otherwise, whereby one business or other entity leases any or all of its workers from another business. Employee leasing arrangements include, but are not limited to, full service employee leasing arrangements, long-term temporary arrangements, and any other arrangement that involves the allocation of employment responsibilities among two or more entities. For purposes of this rule, employee leasing arrangement does not include arrangements to provide temporary help service.
b. Temporary help service shall mean a service whereby an organization hires its own employees and assigns them to clients for a finite time period to support or supplement the client's workforce in special work situations such as employee absences, temporary skill shortages and seasonal workloads.
c. Client (lessee) shall mean an entity that obtains all or part of its workforce from another entity through an employee leasing arrangement or that employs the services of an entity through an employee leasing arrangement.
d. Labor contractor (lessor) shall mean an entity that grants a written lease to a client through an employee leasing arrangement. In this rule, the labor contractor may also be referred to as an employee leasing company.
e. Leased worker (leased employee) shall mean a person performing services for a client under an employee leasing arrangement.
Assigned risk policies are subject to the "multiple coordinated policies" rule which basically requires one carrier to issue a separate policy for each client, all with the same renewal date, with a master invoice sent to the labor contractor. The labor contractor will also have its own policy (the master policy) to cover its direct employees.
Note: Because each state can have different requirements (registration and licensing) for employee leasing arrangements, the ICRB only processes applications for the Indiana portion of a multi-state labor contractor or PEO. For other states, contact NCCI.
Employers involved in employee leasing arrangements will need to complete additional information to tell us about the arrangement so that the proper coverage can be established by the servicing carrier. Answers to the following questions on the ACORD forms will indicate what additional information and forms are needed.
Question #6 - Do you lease workers from a labor contractor? If you answered yes, please complete the Client Supplemental Employee Leasing Application.
Question #7 - Do you lease workers to client companies?
Question #8 - Are you seeking to cover the leased workers?
If you answered yes to Question #7 and to Question #8, please complete the Labor Contractor Supplemental Employee Application side A and side B for each client.
If you answered yes to Question #7 and not to Question #8, please complete the Labor Contractor Supplemental Employee Application side A.
The supplemental employee leasing applications provide us and the carriers with more underwriting information than what we can get by just using the ACORD 130 & 133 forms. Every time the labor contractor gets a new client, we will need an application (with the supplemental applications) for that client. This process allows us to assign a new client to the labor contractor's multiple-coordinated policy (MCP).
A. Labor Contractor Information
- Fully completed WCIP application?
- 941 form furnished?
- Listing of previous names? If none, let us know.
- Listing of ownership for labor contractor?
- Listing of previous owners for last 5 years for labor contractor?
- Listing of the other labor contractors in which the current owners of the applicant has an ownership interest? If none, let us know. Interest in another labor contractor?
- Listing of combinable entities in which the current ownership of the applicant has an interest? If none, let us know.
B. Client Information
- Fully completed WCIP application?
- Client application signed?
- Client 941 form furnished?
- Copy of leasing contract?
- Listing of other labor contractors providing leased employees to client?
- Listing of client's current ownership and listing of any ownership changes in last twelve (12) months?
- Complete description of client operation?
- Listing of leased employees names, social security numbers, class codes and wages?
- Written statement from client indicating current and previous five (5) years carriers and policy numbers?
- Written statement from client listing all previous names the client has operated under in the last five (5) years? If none, let us know.
- Written statement from client stating non-leased employees are covered under a current WC policy with carrier and policy number.
- Listing of non-leased employees which includes number of employees and payroll applicable to each code?
Checklist for Temporary Agency
Question #6 - on ACORD 133 Form "Do you provide temporary labor services to other employers?" If you answered yes, please complete the Temporary Employment Contractor Information form.
Loss Sensitive Rating Plan
The Loss Sensitive Rating Plan (LSRP) is a mandatory assigned risk retrospective rating program for employers whose standard premium is equal to or exceeds $250,000.
In addition to the normal deposit premium, we require an additional LSRP contingency deposit premium of 20% of standard premium, or an acceptable, clean, unconditional irrevocable Letter of Credit (ILOC) containing the automatic renewal clause. All ILOC's must be drawn on a bank that is a member of the Federal Reserve.