Florida Regulations 69O-189.003

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§ 69O-189.003 Workers' Compensation: Application and Audit Procedures.

(1)(a) Each employer applying to a carrier in the voluntary market for workers' compensation coverage required by Section 440.38, Florida Statutes, shall use Form ACORD 130-FL (rev. 7/02), "Florida Workers' Compensation Application," which is hereby adopted and incorporated by reference. Carriers are authorized to continue to use Form ACORD 130-FL (rev. 8/00),

"Florida Workers' Compensation Application," which was previously adopted until the current supply of forms is exhausted. The form shall be completed and submitted to the carrier with which the employer wishes to contract for coverage. (b) A carrier wishing to use its own application form shall submit the form to the Bureau of Property and Casualty Forms and Rates, Division of Insurer Services, Department of Insurance, Larson Building, Tallahassee, FL 32399-0330, and receive approval prior to its use. 1. At a minimum the form shall require the employer to provide the following information: a. Name, address, and legal status of the employer; b. Federal employer identification number; c. Type of business and contractor licensing number if the employer is a contractor; d. Rating information including past and prospective payroll; e. Estimated revenue; f. Locations; g. List of officers, sole proprietors and partners including their social security numbers (disclosure of social security number is voluntary; as an alternative, attach a copy of exclusion or inclusion forms filed with the state); h. List of all employee names, employees' social security numbers and classifications (disclosure of social security numbers is voluntary; as an alternative, the latest UCT-6 form with class codes added can be used in lieu of a separate listing of employee names, employees' social security numbers and classifications); i. Previous workers' compensation experience; j. Former business names and predecessor companies for the last five years; k. Former and current owners in the last five years; l. All names under which the corporation operates; and m. Any other information necessary to enable the carrier to accurately underwrite the employer. 2. The application shall contain a statement that the filing of an application containing false, misleading, or incomplete information with the purpose of avoiding or reducing the amount of premiums for workers' compensation coverage is a felony of the third degree. 3. The application shall contain a sworn statement by the employer attesting to the accuracy of the information submitted. 4. The application shall contain a sworn statement by the agent attesting that the agent explained to the employer or officer the classification codes that are used for premium calculations. (c) Each employer applying for workers' compensation coverage in the Florida Workers' Compensation Joint Underwriting Association (FWCJUA) shall use ACORD Form 130-FL (rev. 7/02) unless the FWCJUA files and receives approval by the Department of Insurance to use a different application form in accordance with paragraph (1)(b). The FWCJUA shall submit any addendum to the application to the Department and receive approval prior to using. The completed application and all addenda shall be submitted to the FWCJUA at the address on the form. (d) The forms adopted in this subsection (1) may be obtained from ACORD, Number 1 Blue Hill Plaza, 15th Floor, Post Office Box 1529, Pearl River, New York 10965-8529. (2)(a) An application complying with this rule is required for all policies having covered Florida exposure. For new business effective after the implementation of this rule, a carrier shall use an application which complies with this rule. When this new business policy is renewed, the carrier is not required to obtain another application. These requirements also apply to policies written in other states where there is covered Florida exposure other than incidental Florida exposure. (b) The applicant's signature on the applicant form shall be notarized. The carrier is authorized to require the producer's signature to be notarized. (3) Each employer in the voluntary market or the FWCJUA may be required by their carrier to submit Form ACORD 175-FL (rev. 3/97), "Florida Workers' Compensation Monthly Change Sheet," which is hereby adopted and incorporated by reference. Carriers may use their own monthly change sheet containing the same information shown on the adopted form. This form is used to reflect any change in the required application. The monthly change sheet is applicable to new and renewal policies which have been issued with an application that complies with this rule. It is not necessary for an employer to submit a monthly change sheet if there are no changes to report. (4)(a) In order to ensure that the appropriate premium is charged for workers' compensation coverage, each employer and carrier shall comply with the requirements of Section 440.381, Florida Statutes, with "Florida State Special Audit Rules", (8/91) and with "Florida Assigned Risk Audit Rules" (7/91). The "Florida State Special Audit Rules" (8/91) and the "Florida State Assigned Risk Audit Rules" (7/91) of the National Council on Compensation Insurance are hereby adopted and incorporated by reference. Copies of the "Florida State Special Audit Rules" (8/91) and the "Florida Assigned Risk Audit Rules" (7/91) are contained in the workers' compensation manual issued by the National Council on Compensation Insurance. (b)1. In addition, each employer shall submit a copy of the quarterly earning report required by Chapter 443, Florida Statutes, to the carrier at the end of each quarter. 2. Each carrier shall develop its own procedures for terminating coverage when the quarterly earning report forms are not received. However, such forms shall be considered timely if received within 45 days of the end of the quarter reported. (c) The carrier shall retain new or renewal applications, monthly change sheets, and the quarterly earning reports for a minimum of three years from the date the applications, sheets, or reports were received. (d) Telephone audits are not permitted in lieu of mail or physical audits. (e) An initial application is required only at the inception of a three-year fixed rate policy or at renewal, if the inception date was prior to the effective date of this rule. Audit procedures are required at the expiration of each policy. Specific Authority 440.381 FS. Law Implemented 440.381, 624.307, 624.308(1) FS. History-New 8-1-91, Formerly 4-28.007, Amended 10-3-95, 10-10-96, 1-15-98, 11-21-00, 11-5-02.