Easy-to-read forms for workers' compensation insurance

Issued and entered September 22, 1983 by Nancy A. Baerwaldt, Commissioner of Insurance

The National Council on Compensation Insurance (NCCI) has prepared an easy-to-read workers' compensation policy with endorsements which it is making available for filing or filing on behalf of its member insurers in most states.

The purpose of this information statement is to inform insurers doing business in Michigan who may wish to file the NCCI easy-to-read forms how to tailor them for use in this state. This bulletin describes the changes that insurers will need to make in the NCCI easy-to-read forms before they can be approved for use in Michigan. It also contains samples of easy-to-read forms that can be approved.

FORMS WITH INSTRUCTIONS

Effective January 1, 1983, workers' compensation insurers doing business in Michigan were prohibited from having forms filed on their behalf by a rating bureau or advisory organization. Since that date, all insurers have had to file their own workers' compensation insurance policy forms. If you wish to use an easy-to-read policy in Michigan, you must file it. No organization can file it on your behalf.

If you wish to file easy-to-read policy forms you should use the procedures and forms contained in Bulletin 76-7, as you would for any other forms filing. Be sure to indicate at the appropriate point on the Forms Submission Data Sheet each of the old forms that you are replacing with an easy-to-read form. If you do file modified NCCI easy-to-read forms, remember that each form needs to be identified with a unique identifying form number.

The nucleus of an easy-to-read policy can be provided by filing three forms: an information page (WC 00 01 01), a workers' compensation and employers liability insurance policy, (WC 00 00 00) and a Michigan Law Endorsement (WC 21 06 01). There is no sample Michigan Law Endorsement in the NCCI Easy-to-Read Forms Manual. For a sample format for this endorsement, refer to Attachment A of this bulletin. You cannot secure approval without a Michigan Law Endorsement.

In addition to these three basic forms, your company probably now has on file many other workers' compensation forms which you may wish to replace with easy-to-read forms. Please note that the Insurance Bureau cannot approve a workers' compensation program that consists partly of easy-to-read and partly of old standard language forms as this would result in a confusing and misleading policy. If you wish to change over to easy-to-read policy forms, you must file all of the endorsements you may wish to use in easy-to-read form. No endorsements are filed on your behalf. You must file even those endorsements that are labeled "standard" by the NCCI if you wish to use them in Michigan.

The following table lists by number NCCI easy-to-read forms that can be used in Michigan, without modifications, to replace existing forms:

ACCEPTABLE NCCI EASY-TO-READ FORMS

If you wish to use any or all of the NCCI retrospective rating plan endorsements WC 00 05 01 through WC 00 05 05 you will need to file, in addition to those endorsements, a form like WC 21 05 02, a sample of which is Attachment B of this bulletin. You will also need to file tables of Retrospective Rating Values in order to use these endorsements. If you wish to supplement the easy-to-read Retrospective Premium Endorsements (WC 00 05 01 through WC 00 05 05) by using a Michigan non-ratable specific disease element, you must file an easy-to-read supplemental endorsement like WC 21 05 01, which is Attachment C of this bulletin.

Your company may presently have on file and wish to replace with easy-to-read forms, three special Michigan endorsements. Easy-to-read forms of these endorsements do not appear in the NCCI Easy-to-Read Forms Manual. Sample endorsements WC 21 06 02, WC 21 06 03 and WC 21 06 04
appear as Attachments D, E, and F to this bulletin.

The sample forms attached to this informational statement contain notes at the bottom of each page. The notes are intended to be instructive. They should not be included on the copies you will issue to your insureds.

Finally, you will find in the NCCI Easy-to-Read Forms Manual several endorsements which cannot be approved for use in Michigan. Do not file in Michigan the following NCCI easy-to-read forms:

If you have questions concerning this bulletin, write or call:

Eric Nordman
Michigan Insurance Bureau
P.O. Box 30220
Lansing, MI 48909
(517) 373-0242