The following policy and endorsements have been filed by the WCRIBMA on behalf of its' membership and have been approved for use in Massachusetts by the Division of Insurance. There are no additional filing requirements with the Division of Insurance if a member carrier of the WCRIBMA wants to use these endorsements.

WC POLICY

Workers Compensation and Employers Liability Insurance Policy	WC 00 00 00 C (pdf)
Information Page	WC 00 00 01 A
General Information Page Notes - Disapproved June 14, 1993	WC 00 00 01 A
Information Page Notes	WC 00 00 01 C

GENERAL ENDORSEMENTS (Approved in Massachusetts)

Defense Base Act Coverage Endorsement	WC 00 01 01 A
Federal Mine Health and Safety Act Coverage Endorsement	WC 00 01 02 B
Federal Employers’ Liability Act Coverage Endorsement	WC 00 01 04 A
Longshore and Harbor Workers’ Compensation Act Coverage Endorsement	WC 00 01 06 A
Nonappropriated Fund Instrumentalities Act Coverage Endorsement	WC 00 01 08 A
Outer Continental Shelf Lands Act Coverage Endorsement	WC 00 01 09 C
Notification Endorsement of Pending Law Change to Terrorism Risk Insurance Program Reauthorization Act of 2007 - withdrawn 01/01/2015	WC 00 01 14
Notification Endorsement of Pending Law Change to Terrorism Risk Insurance Program Reauthorization Act of 2015  - Withdrawn	WC 00 01 15
Maritime Coverage Endorsement	WC 00 02 01 B
Voluntary Compensation Maritime Coverage Endorsement	WC 00 02 03
Alternate Employer Endorsement	WC 00 03 01 A
Designated Workplaces Exclusion Endorsement	WC 00 03 02
Insurance Company as Insured Endorsement	WC 00 03 04
Joint Venture as Insured Endorsement	WC 00 03 05
Partners, Officers and Others Exclusion Endorsement	WC 00 03 08
Rural Utilities Service Endorsement	WC 00 03 09 B
Sole Proprietors, Partners, Officers and Others Coverage Endorsement	WC 00 03 10
Voluntary Compensation and Employers Liability Coverage Endorsement	WC 00 03 11 A
Waiver of Our Right to Recover from Others Endorsement	WC 00 03 13
Domestic and Agricultural Workers Exclusion Endorsement	WC 00 03 15
Professional Employer Organization (PEO) Client Exclusion Endorsement	WC 00 03 22 A
Aircraft Premium Endorsement - withdrawn 1/01/2015	WC 00 04 01
Anniversary Rating Date Endorsement - eliminated 5/01/2017	WC 00 04 02
Experience Rating Modification Factor Endorsement	WC 00 04 03
Pending Rate Change Endorsement	WC 00 04 04
Policy Period Endorsement	WC 00 04 05
Premium Discount Endorsement	WC 00 04 06 A
Rate Change Endorsement	WC 00 04 07
Longshore and Harbor Workers’ Compensation Act Rate Change	WC 00 04 08
Premium Determination Endorsement – Former Self-Insurers 1	WC 00 04 09
Contingent Experience Rating Endorsement	WC 00 04 12
Notification of Change in Ownership Endorsement	WC 00 04 14
Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement	WC 00 04 22 C
Audit Noncompliance Charge Endorsement - Withdrawn May 1, 2021	WC 00 04 24
Experience Rating Modification Factor Revision Endorsement	WC 00 04 25
Retrospective Rating Plan Premium Endorsement – One-Year Plan	WC 00 05 03 C
Retrospective Rating Plan Premium Endorsement – Three-Year Plan	WC 00 05 04 C
Retrospective Rating Plan Premium Endorsement – Wrap-Up Construction Project	WC 00 05 05 C
Retrospective Premium Endorsement – Aviation Exclusion	WC 00 05 08
Retrospective Premium Endorsement – Changes	WC 00 05 09 A
Retrospective Rating Plan Premium Endorsement – Nonratable Catastrophe Element or Surcharge	WC 00 05 10 B
Retrospective Premium Endorsement – Short Form	WC 00 05 11
Retrospective Rating Plan Premium Endorsement – One-Year Plan – Multiple Lines	WC 00 05 12 C
Retrospective Rating Plan Premium Endorsement – Three-Year Plan – Multiple Lines	WC 00 05 13 C
Retrospective Rating Plan Premium Endorsement – Wrap-Up Construction Project - Multiple Lines	WC 00 05 14 C
Retrospective Rating Plan Premium Endorsement - Large Risk Alternative Rating Option (LRARO)	WC 00 05 16
Policy Information Page Endorsement	WC 89 06 00 A

MASSACHUSETTS SPECIFIC ENDORSEMENTS

Massachusetts Terrorism Risk Insurance Program Reauthorization Act Endorsement  - withdrawn 01/01/2015	WC 20 01 01
Massachusetts Notification Endorsement of Pending Law Change to Terrorism Risk Insurance Program Reauthorization Act of 2007 - withdrawn 01/01/2015	WC 20 01 02 (pdf) WC 20 01 02 (word)
Massachusetts Limits of Liability Endorsement	WC 20 03 01
Massachusetts – Assessment Charge	WC 20 03 02 A
Massachusetts Notice to Policyholder Endorsement	WC 20 03 03 E (pdf) WC 20 03 03 E (word)
Massachusetts Professional Employer Organization (PEO) / Employee Leasing Endorsement	WC 20 03 04 D (pdf) WC 20 03 04 D (word)
Massachusetts Exclusion of Coverage for Leased Employees Endorsement (Labor Contractors)	WC 20 03 05 B (pdf) WC 20 03 05 B (word)
Massachusetts Limited Other States Benefit Endorsement	WC 20 03 06 B (pdf) WC 20 03 06 B (word)
Massachusetts Assigned Risk Pool Eligibility Endorsement *	WC 20 03 07
Massachusetts Professional Employer Organization (PEO) Extension Endorsement	WC 20 03 08 (pdf) WC 20 03 08 (word)
Massachusetts Pending Premium Change Endorsement	WC 20 04 01
Massachusetts Qualified Loss Management Program Endorsement	WC 20 04 02 A
Massachusetts Construction Classification Premium Adjustment Endorsement	WC 20 04 03
Massachusetts Premium Due Date Endorsement	WC 20 04 05
Massachusetts Retrospective Premium Endorsement Flexibility Options	WC 20 05 01
Massachusetts Cancellation Endorsement	WC 20 06 01 A
Massachusetts Benefits Deductible Endorsement	WC 20 06 02
Massachusetts Benefits Claim and Aggregate Deductible Endorsement	WC 20 06 03 A (pdf) WC 20 06 03 A (word)
Massachusetts Policy Definition Endorsement	WC 20 06 04

*For use with Assigned Risk Policies only