Table

*Click on form number to view and print forms. Instructional forms include notes.

Form Number Policy and Endorsement Forms
WC 00 00 00C Workers Compensation and Employers Liability Policy
WC 00 00 01A Workers Compensation and Employers Liability Policy Information Page & Extensions
WC 00 01 01A Defense Base Act Coverage Endorsement
WC 00 01 02B Federal Mine Health and Safety Act Coverage Endorsement
WC 00 01 04A Federal Employers' Liability Act Coverage Endorsement
WC 00 01 06A Longshoremen's and Harbor Workers' Compensation Act Coverage Endorsement
WC 00 01 08A Nonappropriated Fund Instrumentalities Act Coverage Endorsement
WC 00 01 09C Outer Continental Shelf Lands Act Coverage Endorsement
WC 00 01 11 Migrant and Seasonal Agricultural Worker Protection Act Coverage Endorsement
WC 00 02 01B Maritime Coverage Endorsement 
WC 00 02 03  Voluntary Compensation Maritime Coverage Endorsement 
WC 00 03 01A  Alternate Employer Endorsement
WC 00 03 02  Designated Workplaces Exclusion Endorsement
WC 00 03 03C  Employers Liability Coverage Endorsement 
WC 00 03 04  Insurance Company as Insured Endorsement 
WC 00 03 05  Joint Venture as Insured Endorsement
WC 00 03 08  Partners, Officers and Others Exclusion Endorsement
WC 00 03 09B  Rural Utilities Service Endorsement
WC 00 03 10  Sole Proprietors, Partners, Officers and Others Coverage Endorsement
WC 00 03 11A  Voluntary Compensation and Employers Liability Coverage Endorsement
WC 00 03 12A  Voluntary Compensation and Employers Liability Coverage for Residence Employees Endorsement
WC 00 03 13  Waiver of Our Right to Recover from Others Endorsement
WC 00 03 14A  Workers Compensation and Employees Liability Coverage for Residence Employees Endorsement
WC 00 03 15  Domestic and Agricultural Workers Exclusion Endorsement
WC 00 03 25  Residual Market Multiple Company Endorsement
WC 00 03 26A  Residual Market Limited Other States Insurance Endorsement
WC 00 04 03  Experience Rating Modification Factor Endorsement
WC 00 04 04  Pending Rate Change Endorsement
WC 00 04 05  Policy Period Endorsement
WC 00 04 06A  Premium Discount Endorsement
WC 00 04 07  Rate Change Endorsement
WC 00 04 12  Contingent Experience Rating Modification Factor Endorsement
WC 00 04 14  Notification of Change in Ownership Endorsement
WC 00 04 19  Premium Due Date Endorsement
WC 00 04 21D Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement
WC 00 04 22B  Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement
WC 00 04 24 Audit Noncompliance Charge Endorsement
WC 00 04 25  Experience Rating Modification Factor Revision Endorsement 
WC 00 05 03C  Retrospective Premium Endorsement One Year Plan
WC 00 05 04C  Retrospective Premium Endorsement Three Year Plan
WC 00 05 05C  Retrospective Premium Endorsement Wrap-Up Construction Project
WC 00 05 08  Retrospective Premium Endorsement Aviation Exclusion
WC 00 05 09A  Retrospective Premium Endorsement Changes
WC 00 05 10B  Retrospective Premium Endorsement Non-Rateable Catastrophe Element or Surcharge
WC 00 05 11  Retrospective Premium Endorsement Short Form
WC 00 05 12C  Retrospective Premium Endorsement One Year Plan - Multiple Lines
WC 00 05 13C  Retrospective Premium Endorsement Three Year Plan - Multiple Lines
WC 00 05 14C  Retrospective Premium Endorsement Wrap-Up Construction Project - Multiple Lines
WC 00 05 15A  Retrospective Premium Endorsement Flexibility Options
WC 00 05 16  Retrospective Rating Plan Premium Endorsement Large Risk Alternative Rating Option (LRARO)
WC 00 06 03  Benefits Deductible Endorsement
WC 32 03 01C  North Carolina Amended Coverage Endorsement
WC 32 03 02   North Carolina Controlled Insurance Program - Amendatory Endorsement (Large Deductible Plans)
WC 32 03 03  North Carolina Controlled Insurance Program - Amendatory Endorsement
WC 32 03 04  Alternative Employer Endorsement (Excluding Employers Liability)
WC 32 03 05 North Carolina Professional Employer Organization (PEO) Exclusion Endorsement 
WC 32 03 06  North Carolina Professional Employer Organization (PEO) Extension Endorsement 
WC 32 03 07  North Carolina Professional Employer Organization (PEO) Client Exclusion Endorsement 
WC 32 03 08  North Carolina Professional Employer Organization (PEO) Client Extension Endorsement 
WC 32 04 15 Assigned Risk Adjustment Program Endorsement
WC 32 04 17 Assigned Risk Loss Sensitive Rating Plan Notification Endorsement
WC 32 04 18 Assigned Risk Loss Sensitive Rating Plan Endorsement
WC 32 06 01A  Cancellation and Non-Renewal Endorsement
WC 32 06 02  Pro-Rata Cancellation Endorsement
WC 89 06 00B  Policy Information Page Endorsement

SEARCH

Go

MEMBER SERVICES

CUSTOMER SUPPORT

2910 Sumner Boulevard, Raleigh, NC 27616 Phone: (919) 783-9790

© 2017 North Carolina Rate Bureau, North Carolina Reinsurance Facility,
North Carolina Insurance Guaranty Association