WC & EL / PART ONE / RULE I:

The system by which no-fault statutory benefits prescribed in state law are provided by an employer to an employee (or the employee’s family) due to a job-related injury (including death) resulting from an accident or occupational disease.

A workers’ compensation insurance policy provides coverage for an employer’s two key exposures arising out of injuries (or death) sustained by employees. Part One of the policy covers the employer’s statutory liabilities under workers’ compensation laws; Part Two of the policy covers the  employer’s liabilities arising out of employees’ work-related injuries (or death) that do not fall under workers’ compensation statutory benefit structure laws.

Standard Policy means the standard provisions of the “Workers’ Compensation and Employers’ Liability Insurance Policy” (WC 00 00 00 C) and the “Information Page” (WC 00 00 01 A) approved by the New York State Department of Financial Services. Every policy affording coverage under the New York State Workers’ Compensation Law must include the following endorsements and premium elements.

MANDATORY ENDORSEMENTS

*These endorsements are not mandatory for the Volunteer Firefighters’ Benefit Law Policy and the Volunteer Ambulance Workers’ Benefit Law Policy.

Exception: Policies covering employees subject to the New York Volunteer Firefighters’ Benefit Law or the New York Volunteer Ambulance Workers’ Benefit Law must be written only by means of a “Volunteer Firefighters’ Benefit Law Policy” (WC 31 00 00 B) or a “Volunteer Ambulance Workers’ Benefit Law Policy” (WC 31 00 02 B), respectively.

MANDATORY PREMIUM ELEMENTS

Note: The Mandatory Premium Elements also apply to the “Volunteer Firefighters’ Benefit Law Policy” (WC 31 00 00 B) and the “Volunteer Ambulance Workers’ Benefit Law Policy” (WC 31 00 02 B).

1. Forms

   Part Four of this Manual contains copies of the following Forms and Endorsements:

   • Standard Workers’ Compensation and Employers’ Liability Insurance Policy
   • Volunteer Firefighters’ Benefit Law Policy
   • Volunteer Ambulance Workers’ Benefit Law Policy
   • Information Pages
   • United States Longshore and Harbor Workers’ Compensation Act Forms
   • Admiralty Law Forms
   • Federal Employers’ Liability Act Forms
   • All endorsement forms approved for use in New York, both countrywide and New York specific

   All forms approved for use in New York may be obtained by contacting the Rating Board or visiting the Rating Board’s website at www.nycirb.org.

   The titles and numbers of all available New York forms and endorsements are shown in the Alphabetical Index and Numeric Index of Endorsements. Refer to Part Four of this Manual for listings.

   Rating Board approval is not required for carriers to use their own attachment clause, letterheads, and/or form numbers. However, any deviation from, modification of, or customization to the wording of any standard form, whether national or New York specific, requires submission to and approval by the Rating Board in addition to filing with and obtaining approval from the New York State Department of Financial Services.

   Note: In accordance with DFS’ Review Standards for Workers’ Compensation and Employers’ Liability, carriers’ policy forms or endorsements that differ from the standard approved forms of the Rating Board (including a change in the form identification number) should be submitted to DFS for approval. Prior to filing for DFS’ approval, individual carrier forms (except where the only change is in the form identification number) should be submitted to the Rating Board in accordance with the Rating Board’s Manual rules for review. Any correspondence a carrier receives from the Rating Board regarding the forms should be included in their submission to DFS.

2. Notes on Forms

   Notes on the various forms and endorsements are for guidance only. They are not to be
   included as part of the form or endorsement.

1. Policies and Renewals

   Copies of all policy Information Pages and renewal certificates must be reported to the Rating Board within thirty (30) days after the effective date of the policy. In addition, proof of coverage must be filed, in electronic format, with the New York State Workers’ Compensation Board within thirty (30) days after the effective date of the policy.

2. Endorsements
   
   
   1. Except as noted in (i) and (ii) below, a copy of every endorsement affecting coverage in New York State must be reported to the Rating Board within thirty (30) days after issue. It is not necessary, however, to report a copy of any endorsement that does not require the insertion of any information relating to coverage on the endorsement, provided:
      
      
      1. Specimen copies of carrier-specific endorsements have previously been submitted to the Rating Board.
      2. The identification number and title or authorized symbol of the endorsement is shown on the Information Page that was reported to the Rating Board.
   2. Endorsements showing a name change, additional insured, additional location, classifications or rates must be submitted within thirty (30) days of the applicable change date.
3. Cancelations or Reinstatements

   As provided by Law, notice of cancellation or reinstatement must be reported to the Rating Board.

4. Classifications
   
   
   1. Authorized Classifications

      Authorized classifications are those that are determined by the Rating Board following a routine, random, or requested review of an employer’s business operation. Each policy insuring a risk for which the classification has been authorized by the Rating Board must be written in accordance with that authorized classification.

   2. Non-Authorized Classifications

      Non–Authorized classifications are those that have not been determined by the Rating Board. Each policy insuring a risk for which the classification has not been authorized by the Rating Board will be written in accordance with classification procedures contained in this Manual and bulletins issued by the Rating Board.

   3. Experience Rated, Non-Experience Rated, and Merit Rated Employers

      Policies for experience rated, non-experience rated, and merit rated employers must be written in accordance with classification procedures contained in this Manual. For these risks, prior Rating Board approval to use a specific classification is not required unless the classification(s) was previously authorized for the risk.

      Note: Experience rating or merit rating factors promulgated by the Rating Board are to be reported on policies. Refer to the New York Experience Rating Plan Manual for rules and procedures applicable to the Experience Rating Plan and the Merit Rating Plan.

1. Policies and Renewals

   Copies of all policy Information Pages and renewal certificates must be reported to the Rating Board within thirty (30) days after the effective date of the policy. In addition, proof of coverage must be filed, in electronic format, with the New York State Workers’ Compensation Board within thirty (30) days after the effective date of the policy.

2. Endorsements
   
   
   1. Except as noted in (i) and (ii) below, a copy of every endorsement affecting coverage in New York State must be reported to the Rating Board within thirty (30) days after issue. It is not necessary, however, to report a copy of any endorsement that does not require the insertion of any information relating to coverage on the endorsement, provided:
      
      
      1. Specimen copies of carrier-specific endorsements have previously been submitted to the Rating Board.
      2. The identification number and title or authorized symbol of the endorsement is shown on the Information Page that was reported to the Rating Board.
   2. Endorsements showing a name change, additional insured, additional location, classifications or rates must be submitted within thirty (30) days of the applicable change date.
3. Cancelations or Reinstatements

   As provided by Law, notice of cancellation or reinstatement must be reported to the Rating Board.

4. Classifications
   
   
   1. Authorized Classifications

      Authorized classifications are those that are determined by the Rating Board following a routine, random, or requested review of an employer’s business operation. Each policy insuring a risk for which the classification has been authorized by the Rating Board must be written in accordance with that authorized classification.

   2. Non-Authorized Classifications

      Non–Authorized classifications are those that have not been determined by the Rating Board. Each policy insuring a risk for which the classification has not been authorized by the Rating Board will be written in accordance with classification procedures contained in this Manual and bulletins issued by the Rating Board.

   3. A-Rated Classifications

      A-rated classifications are those with a symbol (a) noted for the loss cost. Rating Board authorization is required to use A–rated classifications. To obtain approval and the applicable loss cost for an individual employer, a detailed description of the employer’s operations must be submitted to the Rating Board.

   4. Applicability

      Policies for any employer, regardless of experience rating status (i.e. experience rated and  non-experience rated), must be written in accordance with classification procedures contained in this Manual. For these risks, prior Rating Board approval to use a specific classification is not required unless the classification(s) is an a-rated classification or the classification(s) was previously authorized for this risk.

      Note: Experience rating factors promulgated by the Rating Board are to be reported on policies. Refer to the New York Experience Rating Plan Manual for rules and procedures applicable to the Experience Rating Plan.

1. Cancelations

   The New York State Workers' Compensation Board regulates the cancelation of coverage and requires that electronic notice of cancelation be sent to the Chair of the New York State Workers’ Compensation Board:

   1. When cancelation is due to non-payment of premiums, the cancelation shall not become effective until at least ten (10) days after a Notice of Cancelation is served on the employer and is filed with the office of the Chair of the New York State Workers’ Compensation Board.
   2. When cancelation is due to any reason other than non-payment of premiums, the cancelation shall not become effective until at least thirty (30) days after the Notice of Cancelation is served on the employer and filed with the office of the Chair of the New York State Workers’ Compensation Board.

   Note: Other Coverage
   Cancelation of the current policy takes effect on the effective date of other coverage when an employer obtains insurance with another carrier and the effective date of this other coverage is prior to the cancelation date stated in the Notice of Cancelation.

2. Reinstatements

   The policy may be reinstated at any time before the effective date of the cancelation, as shown in the notice. If a policy is to be reinstated, electronic notification of reinstatement must be sent to the Chair of the New York State Workers' Compensation Board.

3. Notice of Intention Not to Renew

   The Law requires that no carrier shall refuse to renew a policy unless notification has been sent to the employer, by registered or certified mail, and has also been filed electronically with the Chair of the New York State Workers' Compensation Board at least thirty (30) days prior to the expiration of the policy.

   Note: Copies of Notices of Cancelation, reinstatements, and non-renewals that have been filed with the Chair of the New York State Workers’ Compensation Board must be reported by carriers to the Rating Board.

4. Conditional Renewal for Carriers Under Common Control

   According to section 54 of the New York State Workers’ Compensation law, if an insurance carrier issues a conditional renewal of a policy that supersedes a policy previously issued by another insurance carrier under common control that will result in an increased premium in excess of ten percent (“Conditional Renewal”), then it shall deliver or mail written notice indicating such intention (“Conditional Renewal Notice”) in the manner described herein. To determine whether the premium increase threshold is met, the proposed premium shall be calculated exclusive of any premium change generated as a result of increased loss costs, increased exposure units, experience rating, contractor credit adjustment program, merit rating, retrospective rating, or audit or removal or reduction of a drug free credit, managed care credit or deductible. A renewal conditioned upon increased premiums equal to or less than 10 percent of current premiums (pursuant to the calculation described above) is not considered a Conditional Renewal and is therefore not subject to the notice requirements of section 54 of the New York State Workers’ Compensation law, which are described herein.

   The Conditional Renewal Notice shall be mailed or delivered in writing to the employer, at the address shown on the policy, and to such employer’s authorized agent or broker, at least thirty days in advance of the expiration date of the policy and shall set forth the amount of the premium increase. If the amount of the premium increase cannot reasonably be determined as of the time the notice is provided due to failure of the policyholder to provide the insurance carrier with the information necessary to determine the premium, the insurance carrier shall provide a reasonable estimate of the premium increase based upon the information available at the time.

   A Conditional Renewal Notice is not required when the employer, an authorized agent or broker, or another insurance carrier of the employer, has mailed or delivered written notice that the policy has been replaced or is no longer desired.

The Rating Board examines and validates policies to verify they are written in accordance with rules and forms contained in the various manuals published by the Rating Board. Carriers are notified when policies are not in compliance with Manual rules by the following means:

• Letters of Criticism and/or
• Online via Manage Data

1. Policies, Renewals, or Endorsements

   The Rating Board will notify carriers when policies, renewals, or endorsements are not written in accordance with Manual rules. Policies and renewal certificates must be reissued or endorsed while incorrect endorsements must be corrected by submitting a new endorsement as required by the Rating Board.

2. Inquiries Regarding Incorrect Policy Issuance

   Complaints of incorrect underwriting will be investigated by the Rating Board, provided the employer or its authorized representative has submitted a written statement of facts including the name of the employer, name of the carrier, and details of the complaint. If an investigation proves the policy was incorrectly written, the carrier must file a copy of a reissued policy or correcting endorsement with the Rating Board within thirty (30) days after notification of the required changes.

   Anyone wishing to appeal a Rating Board decision about the application of a Manual rule or procedure may submit a written request for further review to the Rating Board. Refer to Section (J) of this Rule for further explanation.

Carriers are required to respond to criticisms within the following periods to avoid penalties for non-compliance.

Carriers must furnish the Rating Board with satisfactory evidence of corrections within thirty (30) days. The Rating Board will issue second and third requests in thirty (30) day intervals.

Carriers not furnishing satisfactory correcting evidence within thirty (30) days of the third request are subject to fines for each delinquent item. Additional fines for each will be levied for each additional month during which responses to Rating Board criticisms remain outstanding.

Section 2313, Subdivision (q) of the New York Insurance Law requires the Rating Board to notify the Superintendent of Insurance of any case in which an insurer does not, within sixty (60) days, furnish satisfactory evidence to the Rating Board of the correction of any error or omission previously called to its attention by the Rating Board. Section 2315, Subdivision (e) also makes it an offense, punishable by fine imposed by the Superintendent of Insurance, for any carrier who willfully withholds information from or furnishes false or misleading information to the Rating Board.

1. Written

   The Rating Board will respond to written inquiries received from employers or their authorized representatives. Inquiries must be received by the Rating Board within twelve (12) months of the expiration date of the policy.

2. Telephone

   The Rating Board will accept telephone inquiries on matters such as classification assignments, Manual rule interpretations, ownership rules, and experience modification factors relating to an individual employer, however, it will only do so with authorized parties.

   Telephone inquiries of a general nature, not regarding a specific employer, are answered by Rating Board employees who are knowledgeable in specific subject areas.

   Phone based comments or views expressed by the Rating Board relating to an individual risk are not binding and should be regarded as advisory only.

3. Letters of Authority

   Letters of Authority must be furnished to the Rating Board for non-authorized representatives of employers either:

   1. On the employers’ stationery, authorizing such individuals as their representative and must be signed by an officer, partner, or principal of the employer; or
   2. Through an online application available on the Rating Board’s website at www.nycirb.org.

The application of a rule or procedure contained in this Manual may be appealed. Rules or procedures are defined as those determinations, made by a carrier or the Rating Board, that establish the variables that define policy conditions. Examples include: classification codes, ownership information, premium audits, and any other determination that may affect the policy. The appeal request must be submitted to the Rating Board department executive, with all relevant facts and supporting documentation.

The Rating Board will acknowledge, in writing, receipt of the written appeal request within five (5) business days. It then will communicate next steps – such as, corresponding with carriers, reviewing Rating Board files or, requirements for audits or inspections. The Rating Board will complete a review within sixty (60) days and provide its conclusion, in writing, to the parties.

A request for review will trigger one or more of the following actions:

1. The Rating Board will review the request and respond in writing to the parties within sixty (60) days, either granting the parties or their authorized representatives their request, or sustaining the Rating Board’s original ruling.
2. If not satisfied with the outcome in (1) above, the parties may then request, in writing, a conference with members of the Rating Board staff. The request must state the nature of the complaint and supply any supporting documents. The appropriate Department Vice President or his or her designated representative will preside at the conference.
3. If the dispute is not resolved by conference, the parties may then appeal to the Underwriting Committee of the Rating Board for a hearing to consider the staff ruling. This appeal must be in writing and must specify reasons for the appeal and the nature of the complaint. Following the Committee’s receipt of the appeal request, the parties will be notified about the time and place for a hearing. The appeal request will be heard at the next Underwriting Committee meeting for which appropriate time can be devoted to the matter. After the hearing, the parties will be advised, in writing, of the Underwriting Committee’s decision on the complaint.
4. If the Underwriting Committee ruling is not satisfactory to either party, then the aggrieved party may request a hearing at the New York State Department of Financial Services to consider the disputed decision.
5. The decision of the New York State Department of Financial Services may be appealed to a court of law, by the parties involved or the Rating Board.