ACORD 175 FL (3/97) – Florida Workers Compensation Monthly Change Sheet
The ACORD Florida Workers Compensation Monthly Change Sheet is to be used on new and renewal policies. This form is to be used to request monthly changes to the Florida Workers Compensation application. The form must be used as a result of the passing of Section 3 of CS/HB 3809 (Ch. 90-201) Laws of Florida which was signed into effect July 1, 1990.
The form is designed to be completed by the applicant. It must be mailed to the company writing the Florida Workers Compensation coverage on a monthly basis if a change is to be made. If there are no changes, a monthly change sheet is not mandatory.
This includes policies written by out of state agents that have covered Florida exposure. It is expected that all carriers will be uniformly using this monthly change sheet at this time.
Copies of the monthly change sheet shall be retained for a minimum of three years.
Month/day/year on which the form is completed.
Producer’s name, address and telephone number.
Name of the applicable insurance company. Do not use group names, use the actual name of the company within the group in which you wish to have the policy issued.
This field is used to direct the application to a specific company underwriter by name.
Enter the full name of the applicant as it appears on the original Florida Workers Compensation Application.
Number assigned by the company for the Florida Workers Compensation policy.
Policy Eff. Date
The Effective Date is the date on which the terms and conditions of the policy began.
Pol. Exp. Date
The Expiration Date is the date on which the terms and conditions of the policy will expire.
The address of the insurance company writing the Florida Workers Compensation policy. The company name, address and zip are entered into the white space. This form may be folded at the designated line and mailed in a window envelope.
Enter the new name of the applicant as it should appear on the policy. (The First Named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first.) If joint ownership, the name used may include both names. Example: John and Mary Smith.
Wording such as “et al” or “As their interests may appear” is not acceptable as the name of the insured. These phrases are not legal entities.
The new address at which the First Named Insured is to receive all mail.
The locations that have changed since the initial application or the last monthly change sheet. Place an “X” beside add to enter a new location, or “X” beside delete to delete a location no longer in use. Provide the physical address, not post office boxes. Place an “X” beside Yes or No to show if the applicant is a long termemployee leasing company. Example: Staff Leasing. If yes, then the name of the client and the address where the employees will be located must be included.
Place an “X” for the addition of a new location or class code at the location, “X” for the deletion of an unused location or class code, or “X” if change in class code, categories, duties, classifications, number of employees or estimated remuneration for present policy period.
Street, City, State
The information on this change sheet must match the information provided on the original application or location information on this form.
Enter the location number for each entry which corresponds to the locations listed in the Locations section above.
Enter the Classification Code which best describes the business of the applicant. It is important to remember that it is the business of the employer, not the individual employees, that is being classified. Consult the proper rating manual to determine the code. Rating bureaus may exercise control over classification assignment.
Leave this space blank. The insurer may use this space for special computer codes, to identify the applicable class description wording.
Categories, Duties, Classifications
A single class code may include several related descriptions of activities/operations. Therefore, it is extremely important to enter the specific classification description or, at the very least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
No. of Employees
Indicate the Number of Employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate.
Estimated Remuneration for Present Policy Period
Total estimated payroll expected as a result of this change for the period between the effective date and expiration date.
Add if a new partner, officer, relative; delete if partner, officer, relativesemployment is terminated, or change if the partner, officer, relatives title/relationship, ownership %, duties, inc/exc, class code or remuneration has changed since the original application or previous monthly change sheet.
Enter the name of the partner, executive officer or relative for purposes of indicating whether or not the individual is to be covered by the policy.
Date of Birth
This individual’s birth date.
Provide either the individual’s title within the organization or relationship to the organization’s owners.
Indicate the percentage of ownership the individual has in the organization, if applicable.
Briefly identify the duties of the individual. This will help to ascertain the proper classification.
Indicate if the individual is to be Included or Excluded under the policy coverages.
Enter the Class Code for individuals to be included based on the duties described above.
Provide the estimated annual Remuneration for individuals to be included. Minimum or Maximum remunerations may be applicable based on the state law.
(Be sure to enter the class code and remuneration in the Rating Information section of the application for all included individuals).
Add new employee, delete employee if employment has been terminated, or change due to the name provided on the original application or previous submission of the change sheet is being changed; example due to marital status. If your company has more than six changes in employee names, an “X” must be placed in the box labeled “Check if a list of additional employee names is attached”.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS
Used to describe a revision in the operations and should include an explanation for the revision.
This section is designed to inform the underwriter of what business each applicant performs and the way it is conducted by premises. Operations which may not be apparent in a general description of operations may be segmented by location. Example: location #1 may be the general offices while location #2 may be the warehouse. The section should be completed in enough detail to enable the underwriter to understand and classify each operation. Do not use the classification phraseology from the Commercial Lines Manual or Workers Compensation Manual; it does not provide adequate detail. Example: a manufacturer of pulley wheels used in sewing machines should be described as such and not as “Metal Goods Mfg. N.O.C.”
If the applicant is a manufacturer, describe the:
- Raw materials used
- Processes or work performed
- Products manufactured, who uses them and how they are used
- If the applicant is a contractor, describe the:
- Type of contractor
- Work performed
- Specialized equipment used
- Nature of sub-contracts
If the applicant is a merchant, describe the:
- Type of operation, wholesale or retail (if both, give the Percentage of each)
- Merchandise sold and indicate if of domestic or foreign manufacture
- Services provided
- Whether or not the applicant delivers
If the applicant is a service organization, describe the:
- Type of service performed
- Applicant’s clients (for example, general public, dentists, banks)
Add any additional rating information, comments or other items that will assist in the classification and rating of this risk.
I understand that as the employer, . . .
This section spells out the conditions required of the employer in securing Florida Workers Compensation Coverage.
The applicant’s signature and date the form is completed.
The producer’s signature and date the form is completed.