NEBRASKA

Payment ScheduleOptions:

Estimated                               Minimum                  Payment Basis           Additional

            Annual Premium                        Deposit                                                        Payments

                 $1 to $10,000                           100%                            Annual                     None

                 $1 to $10,000                             75%                            Semi-Annual            One

                 $1 to 10,000                               40%                            Quarterly                 Three

                 $10,001 and greater                    25%                            Monthly                   Eleven

Such additional payments shall be in equal amounts, the sum of which, when added to the deposit premium, shall equal 100% of the estimated annual premium.  Estimated annual premium and the payment schedule are subject to adjustment, interim or final audit, and applicant may select a higher deposit percentage at inception.

Payroll Verification:

Please submit along with application, the employers most recently filed federal employer form (941, 941E, 942 or 943) or equivalent verifiable current payroll record(s) (i.e. Unemployment Wage report).

Effective Date:

Refer to the Plan for postmark binding rules.

Guide to Premium Calculation:

If experience rated, apply the current Nebraska modifier, if available.  If not available, use the modifier from the expiring policy.

Premium Discount, if applicable.

Contractors Credit, if applicable.

Deductible Discount, if elected.

Note:  Applicable Rates and Miscellaneous Values are available on the Nebraska Department of Insurance website at:  NE Assigned Risk Rates

Premium Discount:

The following size-of-risk discount table shall be used:         

First                      $5,000                          0%

Next                    $95,000                     10.9%

Next                  $400,000                     12.6%

Over                  $500,000                     14.4%

Election / Rejection Under State Law:     (Revised effective 1/1/03)

Executive officers of a corporation who own 25 percent or more of the corporation’s common stock will no longer automatically be considered employees of the corporation under the Nebraska Workers’ Compensation Act.   Since the officer will not automatically be covered under the corporation’s workers’ compensation policy, no Corporate Executive Officer Waiver of Rights will be required if the officer chooses not to be covered.  To the contrary, for policies effective January 1, 2003, if such an executive officer wants to be covered as an employee, a written election of such coverage must be filed with the insurer as well as the corporate secretary.  The election is effective upon receipt by the insurer.  Partners and Sole Proprietors are NOT automatically included, but may elect to be included.  To be included, each has to sign a letter of intent.

Coverage for Other States:

The Nebraska Workers’ Compensation Plan applies to Nebraska coverage.  Policies issued under this plan will only cover Nebraska operations.  Should coverage be needed for other states, additional action is required to obtain coverage under applicable state law.  For questions regarding where to apply for coverage in states other than Nebraska, please call the Travelers.

Employee Leasing:

Please make certain the following “General Information” question is answered:

Question 21: Do you lease employees to or from other employers?

If yes, provide information in the “remarks” section explaining the relationship(s). Provide the client company names to which the employees are leased, or the employee leasing company providing workers to the applicant.  You may be asked to complete the Employee Leasing or Labor Contractor Supplemental Application if additional information is required.

Safety Committee Required:

Prior to binding coverage, the applicant must provide written confirmation of its existing safety committee as required by Section 44-3,158.

Note:  Safety Committee Declaration form may be downloaded from the Nebraska Department of Insurance website at:   http://www.doi.ne.gov/workcomp/NEsafety.pdf

Premium Financing:

If premium is financed, please forward the executed finance agreement and/or valid power of attorney, along with the application.

Applicant Information:

Please provide a complete mailing address, telephone number, and Fax number (if applicable).  Also provide the Federal Employers Identification Number (FEIN) or Social Security Number.  Additionally, please provide Inspection, Accounting and Claims information contact Names and Numbers.  (Refer to “General Information” section).

Producer Information:

Please provide a complete mailing address, telephone number, and Fax number (if applicable).  Also provide your License number, Federal Employers Identification Number (FEIN) or Social Security Number.

Application Submission:

A complete ACORD 130 and ACORD 133 Workers’ Compensation Application, required premium or deposit premium, confirmation of Safety Committee and recently filed 941 or equivalent current payroll record must be received prior to binding coverage.  The effective date of the coverage shall be not earlier than the day following the U.S. postmark date of the mailing of the application. 

Refer to the Plan for other effective date rules.

If the following information is missing from the application, the requested effective date may be impacted and the application and deposit may be returned:

o       Physical location in the state of Nebraska

o       Original signature of the officer / owner and the insurance producer

o       Company’s phone number

o       Company’s Federal Employer’s Identification Number (FEIN)

o       Rating information: Class code(s); Estimated Annual Remuneration / Payroll, Rate; and Estimated Annual Manual Premium

o       Premium Calculation (Nebraska Quick Quote tool may be used to assist in calculating the premium – Attaching a Quick Quote calculation is recommended but not required)

o       Prior Carrier Information / Loss History

o       Nature of Business / Description of Operations

Availability of new tool for producers – Nebraska Quick Quote

The Quick Quote is an easy and convenient web based tool to assist you with calculating premiums for

Nebraska Assigned Risk new business.

Access to the Nebraska Quick Quote is provided upon receipt of the Nebraska Quick Quote Application, which can be obtained by contacting the Nebraska Workers Compensation Plan at 1-800-842-9346 or by email at MWCP@Travelers.com. Call the 1-800 number or send an email if you have questions regarding the Nebraska Quick Quote web based tool.

Mail Applications to:

              Regular Mail:                                      Overnight Mail:

Travelers - Nebraska WCIP              Travelers - Nebraska WCIP

P.O. Box 3556                                   2420 Lakemont Avenue

Orlando, FL 32802                           Orlando, FL 32814

Fax: 407-388-3006                          Fax: 407-388-3006

Deposit premium checks should be made payable to:  Travelers Indemnity Company

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Please note that NE WCIP policies will be serviced from the Travelers Service Center in St. Louis, MO.

Travelers Indemnity Company                             Customer Service:     (800) 842-9346

                                                                          FAX number:           (877) 634-3710

Mail correspondence to:                      Overnight correspondence to:

P.O. Box 3556                                   2420 Lakemont Avenue

Orlando, FL 32802                           Orlando, FL 32814