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Workers' CompensationPolicy 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.



UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE

--------------------------------------------------------GENERAL USE/STATE SPECIFIC

--------------------------------------------------------Alabama

WC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC000402 ANNIVERSARY RATING DATE

ENDORSEMENTWC598 11/96 WC0104021196 ANNIVERSARY RATING DATE

ENDORSEMENTWC000415 B 01/10 PWC000415B ASSIGNED RISK ADJUSTMENT PROGRAM

ENDORSEMENTWC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM

ENDORSEMENTWC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING

PLAN ENDORSEMENTWC000423 A 01/08 WC 00 04 23 A ASSIGNED RISK LOSS SENSITIVE

RATING PLAN ENDORSEMENTFOR PROFESSIONAL EMPLOYERORGANIZATION (PEO) AND TEMPORARYARRANGEMENTS

WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATINGPLAN NOTIFICATION ENDORSEMENT

WC504 01/90 WC000411 ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT

WC383 01/90 WC0004130190 ASSIGNED RISK PREMIUM SURCHARGEENDORSEMENT

WC506 01/90 WC000416 ASSIGNED RISK RATING PROGRAMENDORSEMENT

WC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENTWC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING

MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC000101A0492 DEFENSE BASE ACT COVERAGE

ENDORSEMENTWC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSIONWC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL

WORKERS EXCLUSION ENDORSEMENTWC000421 C 09/08 DOMESTIC TERRORISM, EARTHQUAKES,

AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT

WC391 04/91 WC000319 EMPLOYEE LEASING CLIENTENDORSEMENT

WC000322 A 01/06 WC000322A0106 EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT

WC436 02/92 WC000322 EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT

WC000303 C 10/04 WC000303C1004 EMPLOYERS LIABILITY COVERAGEENDORSEMENT

WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT

WC174 04/84 EXTENSION OF INFORMATION PAGE(ITEM 4. PREMIUM)

WC000102 A 11/07 WC000102A FEDERAL COAL MINE SAFETYAND HEALTH ACT COVERAGEENDORSEMENT

WC000104 A 10/04 WC000104A1004 FEDERAL EMPLOYERS LIABILITY ACTCOVERAGE ENDORSEMENT

WC000422 A 09/08 WC000422A FOREIGN TERRORISM PREMIUMENDORSEMENT




WC115 04/84 WC000304 INSURANCE COMPANY AS INSUREDENDORSEMENT

WC116 04/84 WC000305 JOINT VENTURE AS INSUREDENDORSEMENT

WC449 06/92 WC0002040692 LIMITED MARITIME COVERAGEENDORSEMENT

WC419 04/92 WC000106A0492 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT

WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT

WC422 04/92 WC000201A0492 MARITIME COVERAGE ENDORSEMENTWC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION

ENDORSEMENTWC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT

ENDORSEMENTWC463 11/92 WC010401 MERIT RATING ENDORSEMENTWC448 07/92 WC0001110792 MIGRANT AND SEASONAL

AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT

WC000323 A 01/06 WC000323A0106 MULTIPLE COORDINATED POLICYENDORSEMENT

WC437 02/92 WC000323 MULTIPLE COORDINATED POLICYENDORSEMENT

WC420 04/92 WC000108A0492 NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT

WC369 07/90 WC0004140790 NOTIFICATION OF CHANGE INOWNERSHIP ENDORSEMENT

WC421 04/92 WC000109A0492 OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT

(New) WC000000 B 07/11 WC000000B PART TWO EMPLOYERS LIABILITYINSURANCE

WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT

WC129 04/84 WC000404 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B0701 POLICY INFORMATION PAGE

ENDORSEMENTWC130 04/84 WC000405 POLICY PERIOD ENDORSEMENTWC266 07/91 WC000409 PREMIUM DETERMINATION

ENDORSEMENT - FORMER SELF-INSURERS 1

WC000406 A 07/95 WC000406A0795 PREMIUM DISCOUNT ENDORSEMENTWC131 08/84 WC000406 PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC000419 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC000321A0106 PROFESSIONAL EMPLOYER

ORGANIZATION (PEO) EXCLUSIONENDORSEMENT

WC000320 B 01/06 WC000320B0106 PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT

WC433 A 05/97 WC890620C0597 PROOF OF COVERAGE NOTICEWC132 04/84 WC000407 RATE CHANGE ENDORSEMENTWC597 02/97 WC0003260297 RESIDUAL MARKET LIMITED OTHER

STATES INSURANCE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE

COMPANY ENDORSEMENTWC142 04/84 WC000508




RETRO PREMIUM ENDORSEMENTAVIATION

WC340 04/87 WC000509A RETRO PREMIUM ENDORSEMENTCHANGES

WC145 04/84 WC000511 RETRO PREMIUM ENDORSEMENTSHORT FORM

WC000504 B 01/10 WC000504B RETROSPECTIVE PREMIUMENDORSEMENT - RATING OPTION VTHREE YEAR PLAN

WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENTLARGE RISKALTERNATIVE RATING OPTION (LRARO)

WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICEENDORSEMENT

WC608 09/97 WC0104030997 SAFETY INCENTIVE PROGRAMENDORSEMENT

WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT

WC000420 12/02 WC0004201202 TERRORISM RISK INSURANCE ACTENDORSEMENT

WC122 B 08/91 WC000311A0891 VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT

WC636 01/84 WC000311 VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT

WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT

WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT

AlaskaWC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENTWC540403 01/99 WC5404030199 ALASKA RESIDUAL MARKET SAFE

WORKPLACE INCENTIVEWC540501 08/10 WC 54 05 01 ALASKA RETROSPECTIVE RATING PLAN

PREMIUM ENDORSEMENT ONE-YEARPLAN

WC540504 08/10 WC 54 05 04 ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLANMULTIPLE LINES

WC540502 08/10 WC 54 05 02 ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN

WC540505 08/10 WC 54 05 05 ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLANMULTIPLE LINES

WC540503 08/10 WC 54 05 03 ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT

WC540506 08/10 WC 54 05 06 ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT MULTIPLELINES

WC540405 01/08 WC5404050108 ALASKA TERRORISM PREMIUMENDORSEMENT

WC540101 01/08 WC5401010108 ALASKA TERRORISM RISK INSURANCEPROGRAM REAUTHORIZATION ACTENDORSEMENT




WC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC000402 ANNIVERSARY RATING DATE


ENDORSEMENTWC000423 A 01/08 WC 00 04 23 A ASSIGNED RISK LOSS SENSITIVE


WC540404 A 01/03 WC540404A0103 ASSIGNED RISK MANDATORYLOSS SENSITIVE RATING PLANENDORSEMENT


WC465 09/92 WC540401 ASSIGNED RISK PREMIUM SURCHARGEWC383 01/90 WC0004130190 ASSIGNED RISK PREMIUM SURCHARGE

ENDORSEMENTWC506 01/90 WC000416 ASSIGNED RISK RATING PROGRAM

ENDORSEMENTWC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENTWC573 05/95 WC540602 CANCELLATION AND NONRENEWAL

ENDORSEMENTWC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING

MODIFICATION FACTOR ENDORSEMENTWC584 01/96 WC540402 CONTRACTING CLASSIFICATION

PREMIUM ADJUSTMENT ENDORSEMENTWC646 12/03 FORM541CCPAP CONTRACTING CLASSIFICATION

PREMIUM ADJUSTMENT PROGRAMWORKERS COMPENSATION PREMIUMCREDIT APPLICATION

WC217 04/92 WC000101A0492 DEFENSE BASE ACT COVERAGEENDORSEMENT

WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSIONWC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL












WC115 04/84 WC000304




INSURANCE COMPANY AS INSUREDENDORSEMENT


WC572 05/95 WC540301 LIMIT OF LIABILITY ENDORSEMENTWC449 06/92 WC0002040692 LIMITED MARITIME COVERAGE

ENDORSEMENTWC419 04/92 WC000106A0492 LONGSHORE AND HARBOR WORKERS'

COMPENSATION ACT COVERAGEENDORSEMENT




ENDORSEMENTWC448 07/92 WC0001110792 MIGRANT AND SEASONAL





WC424 08/91 WC540601 NOTICE OF INSTALLMENT OPTIONENDORSEMENT








WC131 08/84 WC000406 PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC000419 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC000321A0106 PROFESSIONAL EMPLOYER





COMPANY ENDORSEMENT




WC142 04/84 WC000508 RETRO PREMIUM ENDORSEMENTAVIATION












ArizonaWC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENTWC020401 C 02/10 WC020401C ALCOHOL AND DRUG FREE WORKPLACE

PREM IUM CREDIT ENDORSEMENTWC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC000402 ANNIVERSARY RATING DATE

ENDORSEMENTWC020602 08/02 WC0206020802 ARIZONA BENEFITS DEDUCTIBLE

ENDORSEMENTWC020501 03/02 WC020501 ARIZONA RETROSPECTIVE PREMIUM

ENDORSEMENT LARGE RISKALTERNATIVE RATING OPTIOIN

WC020502 05/02 WC0205020502 ARIZONA SUPPLEMENTALRETROSPECTIVE PREMIUMENDORSEMENT LARGE RISKALTERNATIVE RATING OPTION

WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAMENDORSEMENT

WC000423 A 01/08 WC 00 04 23 A ASSIGNED RISK LOSS SENSITIVERATING PLAN ENDORSEMENTFOR PROFESSIONAL EMPLOYERORGANIZATION (PEO) AND TEMPORARYARRANGEMENTS




WC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENT




WC330 05/86 WC020601 CANCELLATION ENDORSEMENTWC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING









WC603 01/97 WC0203010197 EMPLOYEE LEASING ENDORSEMENTWC000303 C 10/04 WC000303C1004 EMPLOYERS LIABILITY COVERAGE

ENDORSEMENTWC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION

FACTOR ENDORSEMENTWC174 04/84 EXTENSION OF INFORMATION PAGE

(ITEM 4. PREMIUM)WC000102 A 11/07 WC000102A FEDERAL COAL MINE SAFETY

AND HEALTH ACT COVERAGEENDORSEMENT





WC605 01/97 WC0203030197 LABOR CONTRACTOR EXCLUSIONENDORSEMENT


























COMPANY ENDORSEMENTWC142 04/84 WC000508 RETRO PREMIUM ENDORSEMENT

AVIATIONWC340 04/87 WC000509A RETRO PREMIUM ENDORSEMENT

CHANGESWC145 04/84 WC000511 RETRO PREMIUM ENDORSEMENT

SHORT FORMWC000504 B 01/10 WC000504B RETROSPECTIVE PREMIUM

ENDORSEMENT - RATING OPTION VTHREE YEAR PLAN












ArkansasWC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENTWC262 A 04/92 WC030601A AMENDATORY ENDORSEMENTWC127 04/84 WC000402 ANNIVERSARY RATING DATE


ENDORSEMENTWC552 01/94 WC030301 ASSIGNED RISK ASSOCIATED OR

SPONSORED POLICY COVERAGEENDORSEMENT


WC553 01/94 WC030302 ASSIGNED RISK MULTIPLECOORDINATED POLICY COVERAGEENDORSEMENT




WC556 A 10/96 WC030602A1096 BENEFITS DEDUCTIBLE ENDORSEMENTWC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENTWC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING

MODIFICATION FACTOR ENDORSEMENTWC030603 A 07/11 WC030603A CONTRACT HAULING WARRANTY

ENDORSEMENTWC217 04/92 WC000101A0492 DEFENSE BASE ACT COVERAGE












WC000422 A 09/08 WC000422A




FOREIGN TERRORISM PREMIUMENDORSEMENT






WC617 10/97 WC0304041097 MANAGED CARE ENDORSEMENTWC422 04/92 WC000201A0492 MARITIME COVERAGE ENDORSEMENTWC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION


















STATES INSURANCE ENDORSEMENTWC581 06/96 WC000325




RESIDUAL MARKET MULTIPLECOMPANY ENDORSEMENT

WC142 04/84 WC000508 RETRO PREMIUM ENDORSEMENTAVIATION












WC540 03/94 WC030401 WORKERS COMPENSATION INSURANCEPLAN ALTERNATE PREFERRED PLANPREMIUM ENDORSEMENT

WC538 03/94 WC030402 WORKERS COMPENSATION INSURANCEPLAN ASSIGNED RISK TABULARADJUSTMENT PROGRAM PREMIUMENDORSEMENT

WC539 03/94 WC030403 WORKERS COMPENSATION INSURANCEPLAN MERIT RATING ENDORSEMENT

CaliforniaWC040412 11/02 WC0404121102 1999 PREMIUM INCREASE ENDORSMENT

- CALIFORNIAWC040413 11/02 WC0404131102 2000 PREMIUM INCREASE ENDORSMENT



- CALIFORNIAWC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC000402 ANNIVERSARY RATING DATE

ENDORSEMENTWC256 04/84 WC040401 ANNIVERSARY RATING DATE



RATING PLAN ENDORSEMENT




FOR PROFESSIONAL EMPLOYERORGANIZATION (PEO) AND TEMPORARYARRANGEMENTS




WC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENTWC535 12/93 WC040601A CANCELLATION ENDORSEMENTWC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING


ENDORSEMENTWC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSIONWC000421 C 09/08 DOMESTIC TERRORISM, EARTHQUAKES,


WC565 01/95 WC0403100195 DUTY TO DEFENDWC391 04/91 WC000319 EMPLOYEE LEASING CLIENT

ENDORSEMENTWC000322 A 01/06 WC000322A0106 EMPLOYEE LEASING CLIENT

EXCLUSION ENDORSEMENTWC436 02/92 WC000322 EMPLOYEE LEASING CLIENT

EXCLUSION ENDORSEMENTWC387 A 10/98 WC040307A1098 EMPLOYEE LEASING ENDORSEMENTWC626 A 10/98 WC040312A1098 EMPLOYEE LEASING ENDORSEMENT

(FOR LEASING ARRANGEMENTS THATDO NOT FALL WITHIN THE SCOPE OFTHE EMPLOYEE)

WC388 A 10/98 WC040308A1098 EMPLOYEE LEASING ENDORSEMENTSHORT FORM

WC625 A 10/98 WC040311A1098 EMPLOYEE LEASING ENDORSEMENTSHORT FORM (FOR LEASINGARRANGEMENTS THAT DO NOT FALLWITHIN THE SCOPE OF THE EMPLOYEELEASING RULE)

WC040360 A 11/99 WC040360A1199 EMPLOYERS' LIABILITY COVERAGEAMENDATORY ENDORSEMENT


WC7956 F 08/99 FORM 11 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE

WC7606 K 08/99 FORM 10 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE

WC253 04/84 WC040331 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE

WC040317 06/06 WC0403170606 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(EMPLOYEE INSURED BY GENERALEMPLOYER EXCLUDED)

WC040313 09/05 WC0403130905 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(LABOR CONTRACTOR AS NAMEDINSURED - EXCLUSION OF LEASEDEMPLOYEES)

WC040315 09/05 WC0403150905 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE




(LABOR CONTRACTOR AS NAMEDINSURED WITH LCF DESIGNATIONRESTRICTION OF COVERAGE TO CLIENTWORKERS)

WC040316 09/05 WC0403160905 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(LABOR CONTRACTOR AS NAMEDINSUREDEXCLUSION OF CLIENT'SEMPLOYEES)

WC040314 09/05 WC0403140905 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(LABOR CONTRACTOR AS NAMEDINSUREDRESTRICTION OF COVERAGETO CLIENT WORKERS)

WC7815 04/93 NO14 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(LIABILITY NOT INSURED)

WC7805 04/93 NO13 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(LIABILITY NOT INSURED)

WC7802 04/93 FORM 4 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(RELATIVES NOT INSURED)

WC7765 05/94 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE/WORKERS COMPENSATION ANDEMPLOYERS LIABILITY POLICYAMENDATORY ENDORSEMENT

WC255 04/84 WC040337 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE-JOINT VENTURE

WC7967 H 01/84 FORM 7 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE-MEDICAL BENEFITS NOT INSURED

WC354 01/88 WC040410 ESTIMATED ANNUAL PREMIUMENDORSEMENT



WC040005 07/98 WC0400050798 EXTENSION OF INFORMATION PAGECLASSIFICATIONS

WC040004 07/98 WC0400040798 EXTENSION OF INFORMATION PAGESCHEDULE OF FORMS

WC040003 07/98 WC0400030798 EXTENSION OF INFORMATION PAGESCHEDULE OF LOCATIONS

WC040002 07/98 WC0400020798 EXTENSION OF INFORMATION PAGESCHEDULE OF NAMED INSURED

WC040406 C 01/09 WC 04 04 06 C FARM SCHEDULE ENDORSEMENT -CALIFORNIA




WC040411 01/04 WC0404110104(CA) INSOLVENT RATING ADJUSTMENT PLANENDORSEMENT






WC040603 A 01/07 WC040603A0107 LARGE RISK DEDUCTIBLEENDORSEMENT




WC247 A 04/92 WC040101A0492 LONGSHOREMENS AND HARBORWORKERS COMPENSATION ACTCOVERAGE ENDORSEMENT








PN049903 11/99 PN0499031199 NOTICE REQUIRED BY LAWWC369 07/90 WC0004140790 NOTIFICATION OF CHANGE IN

OWNERSHIP ENDORSEMENTWC249 A 01/85 WC040303 OFFICER & DIRECTOR (CA)WC040421 01/08 WC0404210108 OPTIONAL PREMIUM INCREASE

ENDORSEMENT - CAWC421 04/92 WC000109A0492 OUTER CONTINENTAL SHELF LANDS

ACT COVERAGE ENDORSEMENT(New) WC000000 B 07/11 WC000000B PART TWO EMPLOYERS LIABILITY

INSURANCEWC8382 04/76 PARTICIPATING PROVISIONSWC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS

EXCLUSION ENDORSEMENTWC248 B 10/86 WC040302A PARTNERSHIP COVERAGE/EXCLUSION

ENDORSEMENTWC129 04/84 WC000404 PENDING RATE CHANGE ENDORSEMENTWC166 B 03/98 WC040301A0398 POLICY AMENDATORY ENDPN049904 12/01 PN0499041201 POLICY HOLDER NOTICE - CALIFORNIA

INSURANCE GUARANTEE ASSOCIAITON(CIGA) SURCHARGE

PN049905 03/03 PN0499050303 POLICY HOLDER NOTICE - DISCLOSURENOTICE OF TERRORISM INSURANCECOVERAGE NEW AND RENEWALPOLICIES

WC890600 B 07/01 WC890600B0701 POLICY INFORMATION PAGEENDORSEMENT

WC130 04/84 WC000405 POLICY PERIOD ENDORSEMENT




PN049906 01/08 PN0499060108 POLICYHOLDER DISCLOSURE NOTICE OFTERRORISM INSURANCE COVERAGE

PN049902 B 05/02 PN049902B0502 POLICYHOLDER NOTICE (INSURANCERATING LAWS)

PN049901 D 01/11 PN 04 99 01D POLICYHOLDER NOTICE (YOURRIGHT TO RATING AND DIVIDENDINFORMATION)

WC040407 10/99 WC0404071099 PREMIUM ADJUSTMENT ENDORSEMENTWC040409 06/05 WC0404090605 PREMIUM CHANGE EFFECTIVE JULY 1,

2005 ENDORSEMENTWC266 07/91 WC000409 PREMIUM DETERMINATION


WC000406 A 07/95 WC000406A0795 PREMIUM DISCOUNT ENDORSEMENTWC131 08/84 WC000406 PREMIUM DISCOUNT ENDORSEMENTWC000321 A 01/06 WC000321A0106 PROFESSIONAL EMPLOYER








SHORT FORMWC145 04/84 WC000511 RETRO PREMIUM ENDORSEMENT

SHORT FORMWC040501 D 04/08 WC040501D RETROSPECTIVE PREM END [CA]WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE

ENDORSEMENTWC7530 N 01/91 SCHEDULE OF FARM OPERATIONSWC040602 B 12/06 WC040602B1206 SMALL DEDUCTIBLE ENDORSEMENTWC250 A 01/85 WC040304 SOLE PROPRIETOR COVERAGE

ENDORSEMENTWC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS,

OFFICERS AND OTHERS COVERAGEENDORSEMENT

WC040416 01/08 WC0404160108 TERRORISM PREMIUM ENDORSEMENTWC000420 12/02 WC0004201202 TERRORISM RISK INSURANCE ACT

ENDORSEMENTWC040104 01/08 WC0401040108 TERRORISM RISK INSURANCE PROGRAM

REAUTHORIZATION ACT ENDORSEMENTWC251 A 01/85 WC040305 VOLUNTARY COMPENSATION AND

EMPLOYERS LIABILITY COVERAGEENDORSEMENT







WC252 04/84 WC040306 WAIVER OF OUR RIGHT TO RECOVERFROM OTHERS ENDORSEMENT


ColoradoWC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC000402 ANNIVERSARY RATING DATE







WC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENTWC385 11/90 WC0504021190 CLASSIFICATION ENDORSEMENTWC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING














WC642 A 04/03 IMPORTANT NOTICE TOPOLICYHOLDERS





















ENDORSEMENTWC130 04/84 WC000405 POLICY PERIOD ENDORSEMENTWC567 03/93 WC050403 PREMIUM CREDIT FOR CERTIFIED

RISK MANAGEMENT PROGRAMSENDORSEMENT

WC266 07/91 WC000409 PREMIUM DETERMINATIONENDORSEMENT - FORMER SELF-INSURERS 1






COMPANY ENDORSEMENTWC142 04/84 WC000508




RETRO PREMIUM ENDORSEMENTAVIATION












ConnecticutWC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC000402 ANNIVERSARY RATING DATE

ENDORSEMENTWC199 04/84 WC060301 APPLICATION OF WORKERS

COMPENSATION INSURANCEENDORSEMENT

WC000415 B 01/10 PWC000415B ASSIGNED RISK ADJUSTMENT PROGRAMENDORSEMENT


WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATINGPLAN ENDORSEMENT






WC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENTWC060601 01/03 WC0606010103 CONNECTICUT WORKERS'

COMPENSATION FUNDS




WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT

WC588 07/96 WC060401 CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT ENDORSEMENT

WC645 12/03 FORM061CCPAP CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT PROGRAMCONFIDENTIAL WORKERSCOMPENSATION PREMIUM CREDITAPPLICATION

NC5000 A 07/11 FORM NC-5000A CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT PROGRAMWORKERS COMPENSATION PREMIUMCREDIT APPLICATION

NC5000 01/08 FORMNC50000108 CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT PROGRAMWORKERS COMPENSATION PREMIUMCREDIT APPLICATION









WC316 11/92 WC060302 EXCLUDED WORKPLACESENDORSEMENT








WC392 04/91 WC000320 LABOR CONTRACTOR ENDORSEMENTWC449 06/92 WC0002040692 LIMITED MARITIME COVERAGE







WC060602 07/08 WC060602 MANDATORY ARBITRATIONENDORSEMENT





















COMPANY ENDORSEMENTWC146 04/84 WC060501 RETRO PREM SUPP (CT)WC142 04/84 WC000508 RETRO PREMIUM ENDORSEMENT



SHORT FORMWC000504 B 01/10 WC000504B




RETROSPECTIVE PREMIUMENDORSEMENT - RATING OPTION VTHREE YEAR PLAN









DelawareFORM07-1 10/04 FORM0711004 AGREEMENT BY EXCECUTIVE OFFICE

NOTICEFORMDCRB-EX

09/07 FORMDCRBEXCL0907 AGREEMENT BY EXECUTIVE OFFICER(S)/LLC MEMBERS(S) NOT TO BE SUBJECTTO THE DELAWARE WORKERS'COMPENSATION LAW

WC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENTWC184 04/84 WC070303 AMENDATORY ENDORSEMENT

FARMING OPERATIONSWC127 04/84 WC000402 ANNIVERSARY RATING DATE







WC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENTWC375 07/90 WC070402 CONSTRUCTION CLASSIFICATION

PREMIUM ADJUSTMENT ENDORSEMENTWC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING

MODIFICATION FACTOR ENDORSEMENTWC181 04/84 WC070401 DEDUCTIBLE ENDORSEMENTWC217 04/92 WC000101A0492 DEFENSE BASE ACT COVERAGE

ENDORSEMENTWC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSIONWC236 09/85 WC000315




DOMESTIC AND AGRICULTUREALWORKERS EXCLUSION ENDORSEMENT

WC000421 C 09/08 DOMESTIC TERRORISM, EARTHQUAKES,AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT


















ENDORSEMENTWC070408 07/99 WC070408 MERIT RATING PLAN ENDORSEMENTWC448 07/92 WC0001110792 MIGRANT AND SEASONAL





WC358 07/88 WC070601 NONRENEW ENDORSEMENTWC000112 01/05 WC0001120105 NOTIFCATION ENDORSEMENT OF

PENDING LAW CHANGES TO TERRORISMRISK INSURANCE ACT








WC129 04/84 WC000404 PENDING RATE CHANGE ENDORSEMENTWC271 04.08 WC890600 POLICY INFORMATION PAGE

ENDORSEMENTWC890600 B 07/01 WC890600B0701 POLICY INFORMATION PAGE

ENDORSEMENTWC130 04/84 WC000405 POLICY PERIOD ENDORSEMENTWC7949 04/92 POLICYHOLDER NOTICEWC266 07/91 WC000409 PREMIUM DETERMINATION










SHORT FORMWC650 04/84 WC0005090484 RETROSPECTIVE PREMIUM

ENDORSEMENT CHANGESWC120 04/84 WC000309 RURAL ELECTRIFICATION

ADMINISTRATION ENDORSEMENTWC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE

ENDORSEMENTWC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS,







WC651 10/05




WORKERS COMPENSATION PREMIUMCREDIT APPLICATION

District of ColumbiaWC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC000402 ANNIVERSARY RATING DATE










WC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENTWC263 04/84 WC080601 CANCELLATION ENDORSEMENTWC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING











































AVIATIONWC340 04/87 WC000509A




RETRO PREMIUM ENDORSEMENTCHANGES





WC080401 A 09/01 WC080401A0901 SAFE WORKPLACE PRGR ENDT (DC)WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS,







FloridaWC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC000402 ANNIVERSARY RATING DATE

ENDORSEMENTWC8093 C 07/04 FORM09010704 APPLICATION FOR DRUG-FREE

WORKPLACE PREMIUM CREDITPROGRAM






WC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENTWC401 07/90 WC0906050790 BENEFITS DEDUCTIBLE ENDORSEMENTNC3011 10/04 FORMSAFETY931004 CERTIFICATION EMPLOYER

WORKPLACE SAFETY PROGRAMPREMIUM CREDIT

FORM09-3 07/06 FORM0930706 CERTIFICATION OF EMPLOYERWORKPLACE SAFETY PROGRAMPREMIUM CREDIT

WC399 07/90 WC0906030790 COINSURANCE AND DEDUCTIBLEENDORSEMENT




WC400 07/90 WC0906040790 COINSURANCE ENDORSEMENTWC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING

MODIFICATION FACTOR ENDORSEMENTFORM094 C 01/10 CONTRACTING CLASS PREM ADJ(FL)WC483 06/87 WC0904010687 CONTRACTING CLASSIFICATION

PREMIUM ADJUSTMENT ENDORSEMENTWC217 04/92 WC000101A0492 DEFENSE BASE ACT COVERAGE








WC090303 08/05 WC0903030805 EMPLOYERS LIABILITY COVERAGEENDORSEMENT

WC359 10/88 WC090402 EXPER RAT MOD END (FL)WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION

FACTOR ENDORSEMENTWC174 04/84 EXTENSION OF INFORMATION PAGE

(ITEM 4. PREMIUM)WC000102 A 11/07 WC000102A FEDERAL COAL MINE SAFETY

AND HEALTH ACT COVERAGEENDORSEMENT


WC090314 07/07 WC0903140707 FLORIDA EMPLOYEE LEASINGCOMPANY CLIENT COMPANY DIRECTWORKERS INCLUSION ENDORSEMENT

WC090311 07/07 WC0903110707 FLORIDA EMPLOYEE LEASINGCOMPANY CLIENT COMPANYEXCLUSION ENDORSEMENT

WC090312 07/07 WC0903120707 FLORIDA EMPLOYEE LEASINGCOMPANY EXCLUSION ENDORSEMENT

WC090310 07/07 WC0903100707 FLORIDA EMPLOYEE LEASINGCOMPANY EXTENSION ENDORSEMENT

WC090606 10/98 WC0906061098 FLORIDA EMPLOYMENT AND WAGEINFORMATION RELEASE

WC090406 07/10 WC 09 04 06 FLORIDA FOREIGN VOLUNTARYCOMPENSATION AND EMPLOYERSLIABILITY COVERAGE ENDORSEMENT

WC090313 07/07 WC0903130707 FLORIDA MULTIPLE COORDINATEDPOLICY ENDORSEMENT




WC392 04/91 WC000320 LABOR CONTRACTOR ENDORSEMENTWC449 06/92 WC0002040692




LIMITED MARITIME COVERAGEENDORSEMENT










WC641 01/03 NOTICE TO POLICYHOLDERSWC369 07/90 WC0004140790 NOTIFICATION OF CHANGE IN

OWNERSHIP ENDORSEMENTWC421 04/92 WC000109A0492 OUTER CONTINENTAL SHELF LANDS

ACT COVERAGE ENDORSEMENT(New) WC000000 B 07/11 WC000000B PART TWO EMPLOYERS LIABILITY

INSURANCEWC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS

EXCLUSION ENDORSEMENTWC129 04/84 WC000404 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B0701 POLICY INFORMATION PAGE









COMPANY ENDORSEMENTWC589 05/95 WC090501 RETRO PREMIUM END (FL)WC142 04/84 WC000508 RETRO PREMIUM ENDORSEMENT

AVIATION







WC090502 A 01/08 WC090502A0108 RETROSPECTIVE PREMIUMENDORSEMENT FOR NON-RATABLECATASTROPHE ELEMENT ORSURCHARGE



WC090309 01/06 WC0903090106 RURAL UTILITIES SERVICEENDORSEMENT







GeorgiaWC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC000402 ANNIVERSARY RATING DATE









WC370 07/90 WC100602 BENEFITS DED END [GA]WC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENTWC379 A 04/93 WC100601A CANCLTN/NONR/CHG [GA]WC362 01/90 WC000412




CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT














WC100301 11/99 WC100301 GEORGIA EMPLOYEE LEASINGENDORSEMENT

WC100501 11/10 WC100501 GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT ONE-YEAR PLAN

WC100504 11/10 WC100504 GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT ONE-YEAR PLANMULTIPLE LINES

WC100502 11/10 WC100502 GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT THREE-YEAR PLAN

WC100505 11/10 WC100505 GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT THREE-YEAR PLANMULTIPLE LINES

WC100503 11/10 WC100503 GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT WRAP-UP CONSTRUCTION PROJECT

WC100506 11/10 WC100506 GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENTWRAPUP CONSTRUCTION PROJECTMULTIPLE LINES











ENDORSEMENTWC536 01/94 WC100401 MERIT RATING END [GA]WC448 07/92 WC0001110792 MIGRANT AND SEASONAL






















WC000516 01/10 WC 00 05 16




RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENTLARGE RISKALTERNATIVE RATING OPTION (LRARO)








FORM635 B 07/08 WC-131A WORKERS COMPENSATION PREMIUMCREDIT APPLICATION

HawaiiWC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC000402 ANNIVERSARY RATING DATE







WC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENTWC583 01/96 WC520403 CONT CLSFCTN PREMWC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING

MODIFICATION FACTOR ENDORSEMENTNC5000 A 07/11 FORM NC-5000A CONTRACTING CLASSIFICATION

PREMIUM ADJUSTMENT PROGRAMWORKERS COMPENSATION PREMIUMCREDIT APPLICATION

NC5000 01/08 FORMNC50000108 CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT PROGRAMWORKERS COMPENSATION PREMIUMCREDIT APPLICATION



WORKERS EXCLUSION ENDORSEMENTWC000421 C 09/08




DOMESTIC TERRORISM, EARTHQUAKES,AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT










WC520101 01/08 WC5201010108 HAWAII TERRORISM RISK INSURANCEPROGRAM REQUATHORIZATION ACTENDORSMENET







WC422 04/92 WC000201A0492 MARITIME COVERAGE ENDORSEMENTWC329 A 10/89 WC520601A MED BEN DED END (HI)WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION


ENDORSEMENTWC341 03/87 WC520402 MERIT RATING (HI)WC448 07/92 WC0001110792 MIGRANT AND SEASONAL





WC587 01/96 WC520602 NOTIFICATION END (HI)WC369 07/90 WC0004140790 NOTIFICATION OF CHANGE IN

OWNERSHIP ENDORSEMENTWC421 04/92 WC000109A0492




OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT























WC570 04.08 WC000311 VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT





WC140 04/84 WC520401 VOLUNTR WRKRS END (HI)WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM

OTHERS ENDORSEMENTIdaho

WC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC000402 ANNIVERSARY RATING DATE

ENDORSEMENTWC458 09/92 WC110401 ASSGN RISK PREM END [ID]WC000415 B 01/10 PWC000415B ASSIGNED RISK ADJUSTMENT PROGRAM









WC403 02/91 WC0006030291 BENEFITS DEDUCTIBLE ENDORSEMENTWC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING













WC000422 A 09/08 WC000422A




FOREIGN TERRORISM PREMIUMENDORSEMENT

WC110402 A 07/11 WC110402A IDAHO ALCOHOL-AND DRUG-FREEWORKPLACE PREMIUM CREDITENDORSEMENT

WC110601 07/99 WC1106010799 IDAHO COMPENSATIONREIMBURSEMENT OPTIONENDORSEMENT























WC433 A 05/97 WC890620C0597 PROOF OF COVERAGE NOTICE




WC132 04/84 WC000407 RATE CHANGE ENDORSEMENTWC597 02/97 WC0003260297 RESIDUAL MARKET LIMITED OTHER








WC120 04/84 WC000309 RURAL ELECTRIFICATIONADMINISTRATION ENDORSEMENT








IllinoisWC331 05/86 WC000401A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A0289 ALTERNATE EMPLOYER ENDORSEMENTWC120601 D 07/11 WC120601D AMENDATORY END (IL)WC127 04/84 WC000402 ANNIVERSARY RATING DATE









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