Table Of Content

Workers' Compensation Policy Forms and Endorsements ALPHABETICAL INDEX Forms are listed alphabetically by form title. The forms included in this section, which WOLTERS KLUWER FINANCIAL SERVICES’ makes available as stock items, are as follows: 1. Standard and Advisory ‘‘General Use’’ and ‘‘State’’ Endorsements based on National Council on Compensation Insurance (NCCI) text. 2. Endorsements containing ‘‘Tables of Rating Values’’ (used in conjunction with ‘‘Retrospective Premium Endorsements’’). Based on NCCI text. 3. Specific state endorsements in text provided by local Workers Compensation Boards or Bureaus with corresponding Identification Numbers when designated. 4. ‘‘Uncontrolled’’ endorsements (i.e. no industry source) developed by WOLTERS KLUWER FINANCIAL SERVICES’ as a result of individual company demand to satisfy underwriting or state regulatory requirements. Monopolistic Jurisdiction:None of the forms listed herein are for use in the following jurisdictions having a "monopolistic" Workers' Compensation program, except where specifically listed: Ohio, North Dakota, Washington, and Wyoming. Certain Employers Liability forms may, of course, be used even though Workers' Compensation is not used. (New)Denotes change. PAGE WC 1 of 137 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424 Workers' Compensation Policy Forms and Endorsements UNIFORM EDITION BUREAU NUMBER DATE NUMBER TITLE STATE -------------------------------------------------------- GENERAL USE/STATE SPECIFIC -------------------------------------------------------- Alabama WC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENT WC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENT WC127 04/84 WC000402 ANNIVERSARY RATING DATE ENDORSEMENT WC598 11/96 WC0104021196 ANNIVERSARY RATING DATE ENDORSEMENT WC000415 B 01/10 PWC000415B ASSIGNED RISK ADJUSTMENT PROGRAM ENDORSEMENT WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM ENDORSEMENT WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN ENDORSEMENT WC000423 A 01/08 WC 00 04 23 A ASSIGNED RISK LOSS SENSITIVE RATING PLAN ENDORSEMENT FOR PROFESSIONAL EMPLOYER ORGANIZATION (PEO) AND TEMPORARY ARRANGEMENTS WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION ENDORSEMENT WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL ENDORSEMENT WC383 01/90 WC0004130190 ASSIGNED RISK PREMIUM SURCHARGE ENDORSEMENT WC506 01/90 WC000416 ASSIGNED RISK RATING PROGRAM ENDORSEMENT WC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENT WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT WC217 04/92 WC000101A0492 DEFENSE BASE ACT COVERAGE ENDORSEMENT WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION ENDORSEMENT WC000421 C 09/08 DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM ENDORSEMENT WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT ENDORSEMENT WC000322 A 01/06 WC000322A0106 EMPLOYEE LEASING CLIENT EXCLUSION ENDORSEMENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION ENDORSEMENT WC000303 C 10/04 WC000303C1004 EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 A 11/07 WC000102A FEDERAL COAL MINE SAFETY AND HEALTH ACT COVERAGE ENDORSEMENT WC000104 A 10/04 WC000104A1004 FEDERAL EMPLOYERS’ LIABILITY ACT COVERAGE ENDORSEMENT WC000422 A 09/08 WC000422A FOREIGN TERRORISM PREMIUM ENDORSEMENT (New)Denotes change. PAGE WC 2 of 137 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424 Workers' Compensation Policy Forms and Endorsements UNIFORM EDITION BUREAU NUMBER DATE NUMBER TITLE STATE WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED ENDORSEMENT WC116 04/84 WC000305 JOINT VENTURE AS INSURED ENDORSEMENT WC449 06/92 WC0002040692 LIMITED MARITIME COVERAGE ENDORSEMENT WC419 04/92 WC000106A0492 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE ENDORSEMENT WC422 04/92 WC000201A0492 MARITIME COVERAGE ENDORSEMENT WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION ENDORSEMENT WC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT ENDORSEMENT WC463 11/92 WC010401 MERIT RATING ENDORSEMENT WC448 07/92 WC0001110792 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE ENDORSEMENT WC000323 A 01/06 WC000323A0106 MULTIPLE COORDINATED POLICY ENDORSEMENT WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY ENDORSEMENT WC420 04/92 WC000108A0492 NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE ENDORSEMENT WC369 07/90 WC0004140790 NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT WC421 04/92 WC000109A0492 OUTER CONTINENTAL SHELF LANDS ACT COVERAGE ENDORSEMENT (New) WC000000 B 07/11 WC000000B PART TWO— EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT WC129 04/84 WC000404 PENDING RATE CHANGE ENDORSEMENT WC890600 B 07/01 WC890600B0701 POLICY INFORMATION PAGE ENDORSEMENT WC130 04/84 WC000405 POLICY PERIOD ENDORSEMENT WC266 07/91 WC000409 PREMIUM DETERMINATION ENDORSEMENT - FORMER SELF- INSURERS 1 WC000406 A 07/95 WC000406A0795 PREMIUM DISCOUNT ENDORSEMENT WC131 08/84 WC000406 PREMIUM DISCOUNT ENDORSEMENT WC000419 01/01 WC000419 PREMIUM DUE DATE ENDORSEMENT WC000321 A 01/06 WC000321A0106 PROFESSIONAL EMPLOYER ORGANIZATION (PEO) EXCLUSION ENDORSEMENT WC000320 B 01/06 WC000320B0106 PROFESSIONAL EMPLOYER ORGANIZATION (PEO) EXCLUSION ENDORSEMENT WC433 A 05/97 WC890620C0597 PROOF OF COVERAGE NOTICE WC132 04/84 WC000407 RATE CHANGE ENDORSEMENT WC597 02/97 WC0003260297 RESIDUAL MARKET LIMITED OTHER STATES INSURANCE ENDORSEMENT WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY ENDORSEMENT WC142 04/84 WC000508 (New)Denotes change. PAGE WC 3 of 137 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424 Workers' Compensation Policy Forms and Endorsements UNIFORM EDITION BUREAU NUMBER DATE NUMBER TITLE STATE RETRO PREMIUM ENDORSEMENT— AVIATION WC340 04/87 WC000509A RETRO PREMIUM ENDORSEMENT— CHANGES WC145 04/84 WC000511 RETRO PREMIUM ENDORSEMENT— SHORT FORM WC000504 B 01/10 WC000504B RETROSPECTIVE PREMIUM ENDORSEMENT - RATING OPTION V— THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM ENDORSEMENT—LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE ENDORSEMENT WC608 09/97 WC0104030997 SAFETY INCENTIVE PROGRAM ENDORSEMENT WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE ENDORSEMENT WC000420 12/02 WC0004201202 TERRORISM RISK INSURANCE ACT ENDORSEMENT WC122 B 08/91 WC000311A0891 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE ENDORSEMENT WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS ENDORSEMENT Alaska WC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENT WC540403 01/99 WC5404030199 ALASKA RESIDUAL MARKET SAFE WORKPLACE INCENTIVE WC540501 08/10 WC 54 05 01 ALASKA RETROSPECTIVE RATING PLAN PREMIUM ENDORSEMENT ONE-YEAR PLAN WC540504 08/10 WC 54 05 04 ALASKA RETROSPECTIVE RATING PLAN PREMIUM ENDORSEMENT ONE-YEAR PLAN—MULTIPLE LINES WC540502 08/10 WC 54 05 02 ALASKA RETROSPECTIVE RATING PLAN PREMIUM ENDORSEMENT THREE-YEAR PLAN WC540505 08/10 WC 54 05 05 ALASKA RETROSPECTIVE RATING PLAN PREMIUM ENDORSEMENT THREE-YEAR PLAN—MULTIPLE LINES WC540503 08/10 WC 54 05 03 ALASKA RETROSPECTIVE RATING PLAN PREMIUM ENDORSEMENT WRAP-UP CONSTRUCTION PROJECT WC540506 08/10 WC 54 05 06 ALASKA RETROSPECTIVE RATING PLAN PREMIUM ENDORSEMENT WRAP-UP CONSTRUCTION PROJECT MULTIPLE LINES WC540405 01/08 WC5404050108 ALASKA TERRORISM PREMIUM ENDORSEMENT WC540101 01/08 WC5401010108 ALASKA TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT ENDORSEMENT (New)Denotes change. PAGE WC 4 of 137 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424 Workers' Compensation Policy Forms and Endorsements UNIFORM EDITION BUREAU NUMBER DATE NUMBER TITLE STATE WC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENT WC127 04/84 WC000402 ANNIVERSARY RATING DATE ENDORSEMENT WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM ENDORSEMENT WC000423 A 01/08 WC 00 04 23 A ASSIGNED RISK LOSS SENSITIVE RATING PLAN ENDORSEMENT FOR PROFESSIONAL EMPLOYER ORGANIZATION (PEO) AND TEMPORARY ARRANGEMENTS WC540404 A 01/03 WC540404A0103 ASSIGNED RISK MANDATORY LOSS SENSITIVE RATING PLAN ENDORSEMENT WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL ENDORSEMENT WC465 09/92 WC540401 ASSIGNED RISK PREMIUM SURCHARGE WC383 01/90 WC0004130190 ASSIGNED RISK PREMIUM SURCHARGE ENDORSEMENT WC506 01/90 WC000416 ASSIGNED RISK RATING PROGRAM ENDORSEMENT WC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENT WC573 05/95 WC540602 CANCELLATION AND NONRENEWAL ENDORSEMENT WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT WC584 01/96 WC540402 CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT ENDORSEMENT WC646 12/03 FORM541CCPAP CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC217 04/92 WC000101A0492 DEFENSE BASE ACT COVERAGE ENDORSEMENT WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION ENDORSEMENT WC000421 C 09/08 DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM ENDORSEMENT WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT ENDORSEMENT WC000322 A 01/06 WC000322A0106 EMPLOYEE LEASING CLIENT EXCLUSION ENDORSEMENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION ENDORSEMENT WC000303 C 10/04 WC000303C1004 EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 A 11/07 WC000102A FEDERAL COAL MINE SAFETY AND HEALTH ACT COVERAGE ENDORSEMENT WC000104 A 10/04 WC000104A1004 FEDERAL EMPLOYERS’ LIABILITY ACT COVERAGE ENDORSEMENT WC000422 A 09/08 WC000422A FOREIGN TERRORISM PREMIUM ENDORSEMENT WC115 04/84 WC000304 (New)Denotes change. PAGE WC 5 of 137 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424 Workers' Compensation Policy Forms and Endorsements UNIFORM EDITION BUREAU NUMBER DATE NUMBER TITLE STATE INSURANCE COMPANY AS INSURED ENDORSEMENT WC116 04/84 WC000305 JOINT VENTURE AS INSURED ENDORSEMENT WC572 05/95 WC540301 LIMIT OF LIABILITY ENDORSEMENT WC449 06/92 WC0002040692 LIMITED MARITIME COVERAGE ENDORSEMENT WC419 04/92 WC000106A0492 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE ENDORSEMENT WC422 04/92 WC000201A0492 MARITIME COVERAGE ENDORSEMENT WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION ENDORSEMENT WC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT ENDORSEMENT WC448 07/92 WC0001110792 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE ENDORSEMENT WC000323 A 01/06 WC000323A0106 MULTIPLE COORDINATED POLICY ENDORSEMENT WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY ENDORSEMENT WC420 04/92 WC000108A0492 NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE ENDORSEMENT WC424 08/91 WC540601 NOTICE OF INSTALLMENT OPTION ENDORSEMENT WC369 07/90 WC0004140790 NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT WC421 04/92 WC000109A0492 OUTER CONTINENTAL SHELF LANDS ACT COVERAGE ENDORSEMENT (New) WC000000 B 07/11 WC000000B PART TWO— EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT WC129 04/84 WC000404 PENDING RATE CHANGE ENDORSEMENT WC890600 B 07/01 WC890600B0701 POLICY INFORMATION PAGE ENDORSEMENT WC130 04/84 WC000405 POLICY PERIOD ENDORSEMENT WC266 07/91 WC000409 PREMIUM DETERMINATION ENDORSEMENT - FORMER SELF- INSURERS 1 WC131 08/84 WC000406 PREMIUM DISCOUNT ENDORSEMENT WC000419 01/01 WC000419 PREMIUM DUE DATE ENDORSEMENT WC000321 A 01/06 WC000321A0106 PROFESSIONAL EMPLOYER ORGANIZATION (PEO) EXCLUSION ENDORSEMENT WC000320 B 01/06 WC000320B0106 PROFESSIONAL EMPLOYER ORGANIZATION (PEO) EXCLUSION ENDORSEMENT WC433 A 05/97 WC890620C0597 PROOF OF COVERAGE NOTICE WC132 04/84 WC000407 RATE CHANGE ENDORSEMENT WC597 02/97 WC0003260297 RESIDUAL MARKET LIMITED OTHER STATES INSURANCE ENDORSEMENT WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY ENDORSEMENT (New)Denotes change. PAGE WC 6 of 137 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424 Workers' Compensation Policy Forms and Endorsements UNIFORM EDITION BUREAU NUMBER DATE NUMBER TITLE STATE WC142 04/84 WC000508 RETRO PREMIUM ENDORSEMENT— AVIATION WC340 04/87 WC000509A RETRO PREMIUM ENDORSEMENT— CHANGES WC145 04/84 WC000511 RETRO PREMIUM ENDORSEMENT— SHORT FORM WC000504 B 01/10 WC000504B RETROSPECTIVE PREMIUM ENDORSEMENT - RATING OPTION V— THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM ENDORSEMENT—LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE ENDORSEMENT WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE ENDORSEMENT WC000420 12/02 WC0004201202 TERRORISM RISK INSURANCE ACT ENDORSEMENT WC122 B 08/91 WC000311A0891 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE ENDORSEMENT WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS ENDORSEMENT Arizona WC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENT WC020401 C 02/10 WC020401C ALCOHOL AND DRUG FREE WORKPLACE PREM IUM CREDIT ENDORSEMENT WC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENT WC127 04/84 WC000402 ANNIVERSARY RATING DATE ENDORSEMENT WC020602 08/02 WC0206020802 ARIZONA BENEFITS DEDUCTIBLE ENDORSEMENT WC020501 03/02 WC020501 ARIZONA RETROSPECTIVE PREMIUM ENDORSEMENT LARGE RISK ALTERNATIVE RATING OPTIOIN WC020502 05/02 WC0205020502 ARIZONA SUPPLEMENTAL RETROSPECTIVE PREMIUM ENDORSEMENT LARGE RISK ALTERNATIVE RATING OPTION WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM ENDORSEMENT WC000423 A 01/08 WC 00 04 23 A ASSIGNED RISK LOSS SENSITIVE RATING PLAN ENDORSEMENT FOR PROFESSIONAL EMPLOYER ORGANIZATION (PEO) AND TEMPORARY ARRANGEMENTS WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL ENDORSEMENT WC383 01/90 WC0004130190 ASSIGNED RISK PREMIUM SURCHARGE ENDORSEMENT WC506 01/90 WC000416 ASSIGNED RISK RATING PROGRAM ENDORSEMENT WC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENT (New)Denotes change. PAGE WC 7 of 137 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424 Workers' Compensation Policy Forms and Endorsements UNIFORM EDITION BUREAU NUMBER DATE NUMBER TITLE STATE WC330 05/86 WC020601 CANCELLATION ENDORSEMENT WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT WC217 04/92 WC000101A0492 DEFENSE BASE ACT COVERAGE ENDORSEMENT WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION ENDORSEMENT WC000421 C 09/08 DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM ENDORSEMENT WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT ENDORSEMENT WC000322 A 01/06 WC000322A0106 EMPLOYEE LEASING CLIENT EXCLUSION ENDORSEMENT WC604 01/97 WC0203020197 EMPLOYEE LEASING CLIENT EXCLUSION ENDORSEMENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION ENDORSEMENT WC603 01/97 WC0203010197 EMPLOYEE LEASING ENDORSEMENT WC000303 C 10/04 WC000303C1004 EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 A 11/07 WC000102A FEDERAL COAL MINE SAFETY AND HEALTH ACT COVERAGE ENDORSEMENT WC000104 A 10/04 WC000104A1004 FEDERAL EMPLOYERS’ LIABILITY ACT COVERAGE ENDORSEMENT WC000422 A 09/08 WC000422A FOREIGN TERRORISM PREMIUM ENDORSEMENT WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED ENDORSEMENT WC116 04/84 WC000305 JOINT VENTURE AS INSURED ENDORSEMENT WC605 01/97 WC0203030197 LABOR CONTRACTOR EXCLUSION ENDORSEMENT WC449 06/92 WC0002040692 LIMITED MARITIME COVERAGE ENDORSEMENT WC419 04/92 WC000106A0492 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE ENDORSEMENT WC422 04/92 WC000201A0492 MARITIME COVERAGE ENDORSEMENT WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION ENDORSEMENT WC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT ENDORSEMENT WC448 07/92 WC0001110792 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE ENDORSEMENT WC000323 A 01/06 WC000323A0106 MULTIPLE COORDINATED POLICY ENDORSEMENT WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY ENDORSEMENT (New)Denotes change. PAGE WC 8 of 137 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424 Workers' Compensation Policy Forms and Endorsements UNIFORM EDITION BUREAU NUMBER DATE NUMBER TITLE STATE WC420 04/92 WC000108A0492 NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE ENDORSEMENT WC369 07/90 WC0004140790 NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT WC421 04/92 WC000109A0492 OUTER CONTINENTAL SHELF LANDS ACT COVERAGE ENDORSEMENT (New) WC000000 B 07/11 WC000000B PART TWO— EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT WC129 04/84 WC000404 PENDING RATE CHANGE ENDORSEMENT WC890600 B 07/01 WC890600B0701 POLICY INFORMATION PAGE ENDORSEMENT WC130 04/84 WC000405 POLICY PERIOD ENDORSEMENT WC266 07/91 WC000409 PREMIUM DETERMINATION ENDORSEMENT - FORMER SELF- INSURERS 1 WC131 08/84 WC000406 PREMIUM DISCOUNT ENDORSEMENT WC000419 01/01 WC000419 PREMIUM DUE DATE ENDORSEMENT WC000321 A 01/06 WC000321A0106 PROFESSIONAL EMPLOYER ORGANIZATION (PEO) EXCLUSION ENDORSEMENT WC000320 B 01/06 WC000320B0106 PROFESSIONAL EMPLOYER ORGANIZATION (PEO) EXCLUSION ENDORSEMENT WC433 A 05/97 WC890620C0597 PROOF OF COVERAGE NOTICE WC132 04/84 WC000407 RATE CHANGE ENDORSEMENT WC597 02/97 WC0003260297 RESIDUAL MARKET LIMITED OTHER STATES INSURANCE ENDORSEMENT WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY ENDORSEMENT WC142 04/84 WC000508 RETRO PREMIUM ENDORSEMENT— AVIATION WC340 04/87 WC000509A RETRO PREMIUM ENDORSEMENT— CHANGES WC145 04/84 WC000511 RETRO PREMIUM ENDORSEMENT— SHORT FORM WC000504 B 01/10 WC000504B RETROSPECTIVE PREMIUM ENDORSEMENT - RATING OPTION V— THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM ENDORSEMENT—LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE ENDORSEMENT WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE ENDORSEMENT WC000420 12/02 WC0004201202 TERRORISM RISK INSURANCE ACT ENDORSEMENT WC122 B 08/91 WC000311A0891 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE ENDORSEMENT (New)Denotes change. PAGE WC 9 of 137 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424 Workers' Compensation Policy Forms and Endorsements UNIFORM EDITION BUREAU NUMBER DATE NUMBER TITLE STATE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS ENDORSEMENT Arkansas WC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENT WC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENT WC262 A 04/92 WC030601A AMENDATORY ENDORSEMENT WC127 04/84 WC000402 ANNIVERSARY RATING DATE ENDORSEMENT WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM ENDORSEMENT WC552 01/94 WC030301 ASSIGNED RISK ASSOCIATED OR SPONSORED POLICY COVERAGE ENDORSEMENT WC000423 A 01/08 WC 00 04 23 A ASSIGNED RISK LOSS SENSITIVE RATING PLAN ENDORSEMENT FOR PROFESSIONAL EMPLOYER ORGANIZATION (PEO) AND TEMPORARY ARRANGEMENTS WC553 01/94 WC030302 ASSIGNED RISK MULTIPLE COORDINATED POLICY COVERAGE ENDORSEMENT WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL ENDORSEMENT WC383 01/90 WC0004130190 ASSIGNED RISK PREMIUM SURCHARGE ENDORSEMENT WC506 01/90 WC000416 ASSIGNED RISK RATING PROGRAM ENDORSEMENT WC556 A 10/96 WC030602A1096 BENEFITS DEDUCTIBLE ENDORSEMENT WC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENT WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT WC030603 A 07/11 WC030603A CONTRACT HAULING WARRANTY ENDORSEMENT WC217 04/92 WC000101A0492 DEFENSE BASE ACT COVERAGE ENDORSEMENT WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION ENDORSEMENT WC000421 C 09/08 DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM ENDORSEMENT WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT ENDORSEMENT WC000322 A 01/06 WC000322A0106 EMPLOYEE LEASING CLIENT EXCLUSION ENDORSEMENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION ENDORSEMENT WC000303 C 10/04 WC000303C1004 EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 A 11/07 WC000102A FEDERAL COAL MINE SAFETY AND HEALTH ACT COVERAGE ENDORSEMENT WC000104 A 10/04 WC000104A1004 FEDERAL EMPLOYERS’ LIABILITY ACT COVERAGE ENDORSEMENT WC000422 A 09/08 WC000422A (New)Denotes change. PAGE WC 10 of 137 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424

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Workers' Compensation Policy Forms and Endorsements (New)Denotes change. PAGE WC 2 of 137 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424

Policy Forms and Endorsements ALPHABETICAL INDEX Workers PDF

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Workers' Compensation Policy Forms and Endorsements (New)Denotes change. PAGE WC 2 of 137 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424

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