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Filed and Approved Endorsements

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)

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Notification Endorsement of Pending Law Change to Terrorism Risk Insurance Program Reauthorization Act of 2007 - withdrawn 01/01/2015 WC 00 01 14
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
Aircraft Premium Endorsement - withdrawn 1/01/2015 WC 00 04 01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 B
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 D (pdf)
WC 20 03 03 D (word)
Massachusetts Employee Leasing Endorsement WC 20 03 04 B
Massachusetts Exclusion of Coverage for Leased Employees Endorsement WC 20 03 05 A (pdf)
WC 20 03 05 A (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 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





































































Resources

Residual Market Premium Algorithm / Calculator

Voluntary Market Premium Algorithm / Calculator

Class Code Lookup

Experience Rating, ARAP and
Merit Rating Calculator

Experience Rating History

Online MCCPAP - Construction Credit Application

Workers' Compensation Classification
Request Form

The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street, 5th Floor
Boston, MA 02110