A listing, with links, of application forms and endorsements used for businesses applying for or being provided FWCJUA coverage.

FORMS

Please refer to the workers compensation rules published by the National Council on Compensation Insurance (NCCI) and the FWCJUA to complete the below forms. Answer all questions thoroughly as any omission may result in delay, denial or cancelation of coverage.

Application for Coverage Forms  (Tips for Completing Online Application for Coverage)

• ACORD 130 FL (2002/07)
  
  This is the Florida Workers Compensation Application required to be used in the state of Florida for both the voluntary market and the FWCJUA.
  
• ACORD 130 FL Additional Information Form (FWCJUA-130AIF-0111)
  
  This document supplements the ACORD 130 FL Application and the Addendum (ACORD 133 FL) for workers compensation and employers liability insurance to be issued by the FWCJUA. Its content is considered a part of, and is incorporated by reference into, any workers compensation and employers liability insurance policy issued by the FWCJUA.
  
• ACORD 133 FL (2011/01)
  
  This document supplements the ACORD 130 FL Application for workers compensation and employers liability insurance to be issued by the FWCJUA. Its content is considered a part of, and is incorporated by reference into, any workers compensation and employers liability insurance policy issued by the FWCJUA.
  
• ACORD 133 FL Additional Information Form  (FWCJUA-ADDL INFO 133-0111)
This document supplements the ACORD 130 FL Application and the Addendum (ACORD 133 FL) for workers compensation and employers liability insurance to be issued by the FWCJUA. Its content is considered a part of, and is incorporated by reference into, any workers compensation and employers liability insurance policy issued by the FWCJUA.

Employment and Wage Information Release Agreement (FWCJUA-EWIRA-0607)

This document supplements the ACORD 130 FL Application and the Addendum (ACORD 133 FL) for workers compensation and employers liability insurance to be issued by the FWCJUA. Its content is considered a part of, and is incorporated by reference into, any workers compensation and employers liability insurance policy issued by the FWCJUA. By signing this form, the Employer consents to the release of employment and wage information maintained by the State of Florida pursuant to federal and state unemployment compensation laws except to the extent prohibited or limited under federal law to the FWCJUA and its authorized Service Providers.

Supplemental Application Forms

• Horse Trainer Supplemental Application
  
  This supplemental application must be completed by all applicants with horse training, breeding or racing classifications (i.e., Code 7205) and submitted with the application for coverage to measure the size and scope of the operation. The supplemental application will also help determine how the trainer conducts business (i.e., whether employees or independents are being used to exercise, clean and care for the horses as well as what other operations, if any are being conducted by the trainer) for rating purposes.
• Trucker Supplemental Application
  
  This supplemental application must be completed by all applicants with trucking classifications (i.e., Code 7219) or if Code 7380 has the highest payroll and submitted with the application for coverage to help determine the proper state of operation for rating purposes.
• Contractor Supplemental Application
  
  This supplemental application must be completed by all applicants with construction classifications (i.e., Code 5645) and submitted with the application for coverage to help measure the size and scope of the operation and determine how the contractor conducts business (i.e., whether employees or subcontractors are used and what type of licenses are held to properly rate the employer.
• Acknowledgement by Employer of Terms and Conditions of an "If Any" Policy
  
  This form is required if the Employer has no employees at the time of application. By signing this form, the Employer agrees to notify the FWCJUA within 3 business days of hiring an employee and failure to notify the FWCJUA may be considered an intentional misrepresentation, which may result in the cancellation of the policy and in the denial of insurance coverage.

Employee Leasing Application Forms

• Employee Leasing Contractor Supplemental Application & Employee Leasing Client Supplemental Application
  
  These supplemental applications shall provide the FWCJUA and its service provider with more underwriting information than what it can get by just using the ACORD 130 & 133 forms. Leasing Companies are subject to the "multiple coordinated policies" rule which basically requires a separate policy for each client, all with the same renewal date, with a master invoice sent to the Leasing Company. The leasing company shall also have its own policy (the master policy) to cover its direct employees. Refer to the FWCJUA Operations Manual, Part Six, F. 4. Employee Leasing Arrangements for specific instructions on completing these supplemental applications. 
• Employee Leasing – Consent to the Release of Client Initiation or Termination Information
  
  By signing this form the Leasing Company consents to the release of certain information maintained by the State of Florida pursuant to Chapter 468, Florida Statutes.
• Acknowledgement by Labor Contractor and Client of Terms and Conditions of the Multiple Coordinated Policy
  
  By signing this form, the Leasing Company and the client agree to the terms and conditions of the multiple coordinated policy.
• Acknowledgement by Client of the Terms and Conditions of Continued Coverage under the Multiple Coordinated Policy
  
  By signing this form, the client of the Leasing Company being covered under the multiple coordinated policy agrees to continue the coverage afforded through the date of the expiration of the multiple coordinated policy.

Policy Forms

• Employer Affidavit
  
  This form is to be completed quarterly following policy issuance and sent to the FWCJUA's Service Provider 40 days from the end of the fiscal quarter. Execution of this affidavit establishes the Employer's understanding of his/her responsibility under the policy to provide coverage to uninsured subcontractors; acknowledge his/her understanding of potential assessibility relative to uninsured subcontractor's payroll; understands his/her responsibility to reimburse the FWCJUA for any claims paid to or on behalf of subcontractors who are not reported; is aware of potential penalties for failing to report on a quarterly basis subcontractor payrolls, understands what documents are required at audit in order to exclude subcontractors' payrolls; and attests to the truthful nature of the information being provided.
• Quarterly Payroll Reporting Form
  
  Each policyholder on a quarterly basis is required to complete the reporting form together with the Employer's Affidavit and forward both forms to the FWCJUA policy administration service provider along with the most recently filed Employer's Quarterly Tax Report (UCT-6) to adjust payrolls accordingly, if necessary, to avoid potential uncollectible premium by the end of the policy term.
• ACORD 175 (Monthly ChangeSheet)
  
  This form is to be completed by the employer and mailed to the FWCJUA on a monthly basis if a change is to be made on the policy. If there are no changes, a monthly change sheet is not mandatory.

Other Forms

• ERM – 14 Form – Confidential Request for Ownership Information
  
  This form must be completed within 90 days when there is a change in entity regarding name, structure and/or ownership. This form should also be completed if the Employer forms a new or related entity.
• Application for $2,500 Deductible Plan
  
  This form must be completed and submitted to the FWCJUA if an employer is interested in a small deductible program. Eligible employers may pay for each injury for which an employee files a claim as a deductible, up to the first $2,500 of the total amount payable under compensable claims related to such injury. Any amounts paid by the employer will not apply to the experience rating of such employer, but must be reported for ratemaking purposes. There is no premium credit associated with this plan.
• Application for Drug-Free Workplace Premium Credit Program (Form 09-1)
  
  An employer who establishes a drug-free workplace may apply to qualify for a premium credit under the Florida Drug-Free Workplace Premium Credit Program. Please refer to the NCCI Basic Manual, Florida Miscellaneous Rules for the rules related to this premium credit program.
• Application for Employer Workplace Safety Program Premium Credit (Form 09-3)
  
  An employer who establishes a Safety Program in accordance with Section 440.1025, Florida Statutes, may apply to qualify for a premium credit under the Florida Employer Safety Premium Credit Program. Please refer to the NCCI Basic Manual, Florida Miscellaneous Rules for the rules related to this premium credit program.
• Payroll Service With Premium Withholding Agreement
  
  This form must be completed by Employer's who elect to participate in the FWCJUA's Optional Payroll Service With Premium Withholding Program to help reduce upfront costs. The program is only available to employers with payroll. Refer to the FWCJUA Operations Manual, Part Six, D.2.c., for eligibility criteria.

Agency Forms

• Agency Producer Agreement (Viewing Copy Only - NOT for completion & execution)
  This form must be completed by Agency's and Designated Producer's to obtain authorization from the FWCJUA to submit Applications for Coverage to the FWCJUA or directly or indirectly receive compensation in connection with business written by the FWCJUA. Click here Agency Authorization to be redirected to the Agency Authorization section of the website to access the Agreement for completion and execution purposes.
• Agency Producer Agreement Addendum to Exhibit A
  This form is used to add or delete Designated Producer or Customer Service Representative (CSR), from the Agency Producer Agreement authorized by the FWCJUA, rather than requiring completion of a new Agreement. The Addendum to Exhibit A is not meant to replace the original Exhibit A, but simply to add and/or delete information from the original Agreement.

ENDORSEMENTS

Committing FRAUD is a crime!!