Worker's Comp (California) Application

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Description

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Named Insured

Legal name of the business entity applying for Workers Compensation coverage.

Named Insured Address

Business mailing address, including street, city, state, and ZIP code.

Entity Type

Structure of the business (e.g., Corporation, LLC, Partnership, Sole Proprietor).

Federal Employer Identification Number (FEIN)

Tax ID used to identify the business.

Requested Policy Effective Date

Desired start date for Workers Compensation coverage.

Requested Policy Expiration Date

Desired end date for the initial coverage term.

Insurance Carrier Name

Name of the insurer to which this application is being submitted.

Classification Codes

Applicable WCIRB classification code(s) corresponding to business operations.

Estimated Annual Payroll by Classification

Projected payroll for each job classification used to calculate premium.

Experience Modification Rating (Ex-Mod)

Modifier applied based on the applicant’s prior loss experience.

Bodily Injury by Accident Limit

Per-incident payout limit for physical injuries.

Bodily Injury by Disease Limit (Per Employee)

Maximum benefit paid per employee for occupational disease claims.

Policy Limit for Disease (Aggregate)

Total payout limit for all disease claims during the policy period.

Each Occurrence Deductible

Deductible amount the insured is responsible for per claim.

All States Endorsement

Requested to extend WC coverage to other U.S. states beyond California.

Voluntary Compensation Endorsement

Request to cover workers who are not legally required to be covered.

U.S.L. & H. Act Endorsement

Request to provide coverage for employees subject to the U.S. Longshore & Harbor Workers’ Compensation Act.

Jones Act Coverage

Requested to provide maritime coverage for employees under the Jones Act.

Stop Gap Coverage

Coverage requested for liability exposure in monopolistic WC states (if applicable).

Formal Workplace Safety Program in Place

Indicates whether the applicant maintains an official written safety program.

Certified Drug-Free Workplace Program

Indicates whether the applicant participates in a certified drug-free workplace program.

Medical Provider Network (MPN) Usage

States whether the applicant uses a designated MPN for managing WC claims.

Included / Excluded Individuals

List of owners, officers, or managing partners with indication of coverage inclusion or exclusion.

Reporting Form Agreement

Indicates whether the applicant agrees to declare payroll via reporting form.

Audit Acknowledgment

Acknowledges that final premium is subject to year-end audit based on actual payroll.

California workers’ compensation applications capture essential applicant, insurer, and coverage details for accurate classification, rating, and underwriting. Feathery’s AI extraction engine automates this by pulling the named insured, business address, entity type, FEIN, effective and expiration dates, insurance carrier, WCIRB classification codes, estimated payroll per classification, and experience modification rating. Limits of insurance and deductibles, including bodily injury by accident, bodily injury by disease, aggregate disease limits, and per-occurrence deductibles, are also extracted.

The engine identifies requested endorsements such as All States coverage, voluntary compensation, U.S. Longshore & Harbor Workers’ Act coverage, Jones Act coverage, and stop gap coverage. Safety declarations, including workplace safety programs, certified drug-free participation, and medical provider network usage, are returned along with included or excluded personnel listings. Policy condition acknowledgments like reporting form agreements and audit requirements are also captured, helping carriers, MGAs, and brokers process applications faster, improve rating accuracy, and streamline policy issuance.

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