Documents & Resources All documents and forms being provided for your reference and use are located in the appropriate secure, password protected section of our website. Listed below are links to industry related information and online tools you may find helpful. Agent Resources & Documents Agent of Record Letter Procedure This document provides information and instructions regarding submitting an Agent of Record Letter. Authorization Form for Direct Deposit/Payment of Commission Checks This form gives us the necessary information necessary to deposit commission payments directly into the agency’s bank account. Confidential Request for Information ERM-14 This form is used to notify FCBI/NCCI Workers’ Comp of changes in business ownership. Policyholders should contact their agent for assistance in completing this form. Construction Codes List A listing of NCCI construction class codes based directly on the Florida Division of Workers’ Compensation’s official list of NCCI class codes that the State of Florida considers to be in the construction industry. Construction Operations Supplemental This form is used by our Underwriters for businesses in the construction industry and must be completed and signed by an owner/officer of the company. FCBI Supplemental Application Participation Agreement This form is the supplemental application policyholders are required to sign at binding. Florida Contracting Classification Premium Adjustment Program Application (FCCPAP) Policyholders use this form to apply for a premium adjustment based on their contracting classification. This form is sent to the National Council on Compensation Insurance (NCCI). NCCI Drug-Free Premium Credit Application Policyholders use this form to apply for a premium credit based on their drug-free workplace policy. This application and a copy of the program are required in order to receive credit on the policy. NCCI Safety Premium Credit Application Policyholders use this form to apply for a premium credit based on their safety program. This application and copy of the program are required to receive credit on the policy. Telecommunications Operation Supplemental This form is used by our underwriters for businesses in the Telecommunications/Cable industry and must be completed and signed by an officer/owner of the company. Waiver of Subrogation Endorsement Instructions This document contains information and instructions on how to apply for a waiver of subrogation endorsement. Waiver of Subrogation Endorsement Request This is the form referenced in the previous document which provides the Underwriter the necessary information to review the endorsement request. Policyholder Resources & Documents ACH Recurring Payment Authorization Form This is used to register for Recurring Payments Construction Policy Tracking Database This is an online tool that provides information to contractors regarding the coverage status of the contractors they use. Exemption Application – DWC 250 – Online Application This online application is used to apply and pay for an exemption from workers’ compensation insurance. Revocation of Election to be Exempt – DWC 250 R This form is used to revoke a currently held exemption from workers’ compensation insurance. Election of Coverage – DWC 251 This form is used by those partners and sole proprietors in the non-construction industry to elect to be covered by workers’ compensation and therefore eligible for workers’ compensation benefits. Revocation of Election of Coverage – DWC 251-R This form is used by partners and sole proprietors to revoke an election of coverage and waives their right to workers’ compensation benefits should they be injured on the job. First Report of Injury or Illness Form – DWC 1 This form is used to report all workplace accidents. Florida Division of Workers’ Compensation Website This website explains general information about employers’ responsibilities under the Florida workers’ compensation law. Manage Workers’ Compensation Costs – Simple Rules This document provides eight simple rules to help control your costs related to workers’ compensation insurance. Non-Compliance Violations This website explains the penalties for not complying with Florida’s workers’ compensation coverage requirements. Policyholder Payments This is a printable reference page providing the pertinent information on the three ways to make payments. Proof of Coverage Database This state database is used to verify coverage or the exempt status of employers. Contractors can use this database to verify that their subcontractors’ exemptions or workers’ comp policies are valid. Sunbiz.org This website allows employers to see which officers are listed for a corporation (Inc) or a limited liability company (LLC) and are therefore eligible to file an exemption. Work-Related Injuries Reporting Wall Card – English This is a wall card policyholders should post near their workers’ compensation poster with instructions on how to file a workers’ compensation claim. Work-Related Injuries Reporting Wall Card – Spanish This is a wall card policyholders should post near their workers’ compensation poster with instructions on how to file a workers’ compensation claim in Spanish.