General Information

Employer Name

This is the legal name of the Employer.

• Enter the legal name of the Employer.
• This entry is optional.

Business Type (Legal Status of Company)

This is the business type/legal status of the employer.

• Select the appropriate business type/legal status from the drop-down list.
• A selection is required for estimate generation.

Effective Date

This is the desired effective date of the policy.

• Enter or select the desired effective date.
• Date format MM/DD/YYYY.
• Valid date cannot precede current date or exceed 60 days from the current date.
• A valid date is required for estimate generation.

Assigned Tier

There are established rating tiers for various classifications of risk which reflect risk of loss, hazard grade, actual losses, size of premium, and compliance with loss control. All Employers shall be assigned to one of three rating tiers.

• Select appropriate assigned tier for the employer using drop-down selector.
• Tier explanation can be found on the Tier Eligibility page accessed by clicking on the "Tier Eligibility" link on the page header.
• Tier selection defaults to Tier 3.

Increased Employer's Liability Limits

Increased Limits will provide additional protection against the common law liability of an Employer for accidents to employees, as distinguished from the liability imposed by a workers’ compensation law. The state’s statutory limits will be automatically included in any workers’ compensation policy. However, coverage limits in excess of the statutory limits will increase your policy premium. The limits are defined as follows:

• Select the desired limits from the drop-down list.
• Limits Per Accident for bodily injury by accident.
• Limits Per Employee for bodily injury by disease.
• Policy Limits for bodily injury by disease.
• Limits displayed should be multiplied by 1,000 for the actual value.
• A selection is required for estimate generation.

Billing Plan

There are three plans offered. Below is a detailed description for each billing plan.

• Option 1: Payment in Full of TEAP and any Required Deposit Premium - Option 1 is mandatory if the Employer’s Total Estimated Annual Premium (TEAP) is less than or equal to $1,000, unless the Employer qualifies for and selects Option 3. Any Employer may choose to pay their TEAP in full. 100% of the advance premium and deposit premium is due prior to binding coverage. This option must be chosen if the Employer is going to finance their premium with a Premium Finance company.
• Option 2: Advance Premium Payment Plan plus Payment in Full of any Required Deposit Premium - Option 2 offers a premium installment payment plan if the Employer’s TEAP exceeds $1,000. A 50% advance premium payment of the TEAP and 100% of the required deposit premium is due before binding coverage. In addition, the Employer is required to make payments equal to 50% of the TEAP in 3 equal installments payable 3, 6, & 9 months from policy inception.
• Option 3: Payroll Service with Premium Withholding Program Payment Plan - No Deposit Premium Required - Option 3 offers a premium installment payment plan with no deposit premium requirement if the Employer is reporting and will maintain employees with payroll on the policy. Certain restrictions apply - see the FWCJUA Operations Manual for details. This plan requires the Employer to execute an application agreement and the required service agreement(s) with an FWCJUA authorized Payroll Service Partner. The advance premium requirement is reduced to 16.7% which is required before binding coverage.
• A selection is required for estimate generation.

Experience Mod

If the Employer is experience rated, please enter the experience mod factor that will be applicable for this policy. If the Employer is not experience rated or the experience mod is not known, leave blank.

• Enter the experience mod with format #.##
• The Experience Mod will be evaluated to verify the Assigned Tier.
• Experience Mod restrictions on Assigned Tiers can be found on the Tier Eligibility page.
• This entry is optional.

ARAP

The Assigned Risk Adjustment Program (ARAP) Surcharge is calculated as a function of the experience rating procedure. If the Employer qualifies, the policy premium will be calculated with an (ARAP) Surcharge. Decimals are allowed. This is not a required field.

• Enter the ARAP with format #.##.
• Accepted ARAP range is 1.00 to 1.49, defaults to 1.00.
• ARAP surcharges only applied to Tier 3 assignments.
• This entry is optional.

New Business

Select "Yes" if the Employer is a new business.

For purposes of Tier 1 and Tier 2 eligibility, means a business enterprise, regardless of business form, which began business operations, such as the sale of goods or the rendition of services, within six months prior to the date the Application for Coverage is received by the FWCJUA. A mere change in the business form of the Employer does not constitute the creation of a new business. For example, a new business is not created when a Sole Proprietor creates a corporation or a limited liability company to transact the same or similar business to that previously transacted by the Sole Proprietor. Furthermore, changes in ownership interest that would result in the continuation of experience if the existing business enterprise were subject to the Experience Rating Plan, shall not result in the creation of a new business.

• Assignment of Tier 1 is unavailable to new businesses.
• The Assigned Tier will be re-evaluated for availability on selection.
• A selection is required for estimate generation.

Coverage Lapse

Select "Yes" if the Applicant has a lapse in Workers Compensation Coverage.

For purposes of Tier 1 and Tier 2 eligibility, continuous workers' compensation coverage has been in force, and is still in force, at the time of application to the FWCJUA. Otherwise, there is a lapse in coverage.

• Assignment of Tier 1 is unavailable to Employers with a lapse in coverage.
• The Assigned Tier will be re-evaluated for availability on selection.
• A selection is required for estimate generation.

Lost Time Claims

Select 'Yes' if the Employer has any 'Lost Time' claims within the past 3 years.

For purposes of Tier 1 and Tier 2 eligibility, any claims against a workers' compensation policy for a covered employee(s) absent from work for more than eight days because of a work related injury or serious occupational disease constitutes a lost time claim (aka indemnity claim).

• Enter the experience mod with format #.##
• Assigned Tier 1 and 2 are unavailable to Employers with "Lost Time" claims.
• The Assigned Tier will be re-evaluated for availability on selection.
• A selection is required for estimate generation.

Class Codes & Payroll

To add a class code to the estimate:

• Click on the Add Class Code  button.
• Select and/or fill in the necessary fields.
• Click on the Save Class Code button to add, or the Cancel button to exit the Class Code entry screen and display included Class Codes.
• Repeat as desired.

Class Code

Use the filter box to enter a complete or partial class code or class code description to filter the list below. Click on the desired Class Code / Description to select and populate the Class Code input.

• A class code followed by the letter "F" will include premium for operations subject to the USL&H Act.
• Class code "5551 - Roofing - All Kinds & Yard Employees" will trigger a minimum payroll calculation.
• Class code "7704 - Firefighters & Drivers" will trigger a minimum payroll per volunteer if payroll is less than $1000.

Coverage Type

Select the coverage type for the classification.

• Use the drop-down selector to add USL&H coverage if necessary.
• A class code followed by the "F" is pre-loaded to provide USL&H coverage.

Number of Employees

The number of employees assigned to the class code.

• Only required if class code is rated on a per capita basis.

Payroll

The total estimated annual of payroll per class code.

• Enter the total estimated annual payroll for the class code.
• Entry is required. If no payroll, enter 0.

Officer/Sole Proprietor/Managing Member/Partner Information

To include an Officer/Sole Proprietor/Managing Member/Partner in the estimate:

• Corporate Officers are considered employees under the law and will be covered under an FWCJUA policy unless the officers file for exemption.
• Sole Proprietors and Partners in a non-construction industry will not be covered under an FWCJUA policy unless the Sole Proprietor or Partner files for an election of coverage.
• In the Construction Industry, Officers and Members are automatically covered under an FWCJUA policy unless the Officers or Members elect to be exempt from coverage.

To add an officer/owner/managing member/partner to the estimate:

• Click on the Add Officer/Proprietor/Member/Partner  button.
• Select and/or fill in the necessary fields.
• Click on the Save Individual button to add, or the Cancel button to exit the entry screen and display included Individuals.
• Repeat as desired.

Name

The name of the individual officer.

• A name is required to add an officer.

Class Code

Use the filter box to enter a complete or partial class code or class code description to filter the list below. Click on the Class Code / Description that best describes the activity performed by the individual.

• A class code followed by the letter "F" will include premium for operations subject to the USL&H Act.
• Class code "5551 - Roofing - All Kinds & Yard Employees" will trigger a minimum payroll calculation.
• Class code "7704 - Firefighters & Drivers" will trigger a minimum payroll per volunteer if payroll is less than $1000.

Coverage Type

Select the coverage type for the classification.

• Use the drop-down selector to add USL&H coverage if necessary.
• A class code followed by the "F" is pre-loaded to provide USL&H coverage.

Payroll

The amount of payroll/remuneration for the individual officer.

• A value of 0 can be used. A minimum payroll may be calculated
• Please refer to the Miscellaneous Values Page in the FWCJUA Operations Manual for the minimum and maximum remuneration applicable.

Waivers of Subrogation

To add a waiver to the estimate:

• Click on the Add Waiver of Subrogation  button.
• Select and/or fill in the necessary fields.
• Click on the Save Waiver button to add, or the Cancel button to exit the entry screen and display included waivers.
• Repeat as desired.

Class Code

Use the filter box to enter a complete or partial class code or class code description to filter the list below. Click on the Class Code / Description that best describes the activity performed by the employee(s).

• Use the drop-down selector to select a classification code.
• At least on class code must be entered on the "Class Codes" screen to populate the list.

Coverage Type

Select the coverage type for the classification.

• Use the drop-down selector to add USL&H coverage if necessary.
• A class code followed by the "F" is pre-loaded to provide USL&H coverage.

Number of Employees

The number of employees to whom the classification/waiver applies.

Payroll

The amount of payroll generated per the classification code for the waiver.