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.
Authorization Form for Amending the Original Direct Deposit/Payment of Commission Checks Form
This form gives us the necessary information for any changes that need to be made to your original Direct Deposit Form.
Authorization Form for Electronic Correspondence
This form gives us the information necessary to send regular agency correspondence, such as new and renewal policies, cancellations, reinstatements and endorsements, via email.
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 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.
Ladder and Scaffold Training Materials – English Version
These training materials teach employees to 1) understand how to choose, inspect, and use ladders correctly and 2) be aware of general safety requirements for scaffold users.
Ladder and Scaffold Training Materials – Spanish Version
These training materials teach employees to 1) understand how to choose, inspect, and use ladders correctly and 2) be aware of general safety requirements for scaffold users in Spanish.
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.

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