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STATE NOTES: POLICY TERMINATION/CANCELATION/REINSTATEMENT NOTICE 6th Reprint Issued August 27, 1998

WC 89 06 09 B

I. BACKGROUND
The National Council on Compensation Insurance, Inc. (NCCI) has developed and implemented the Policy Issue Capture System (PICS). Under this system, NCCI captures and stores all workers compensation policy data. The policy data is obtained from the policy documents submitted by insurers to NCCI. (Insurers also have the option of submitting this data electronically to NCCI.) The Policy Issue Capture System has been developed to fulfill three basic functions. One is to provide actuarial information that can be used to control the quality of ratemaking data. The second function is to provide a control over the submission of unit statistical reports. The third function of PICS is the reporting of coverage data to state workers compensation agencies (i.e., industrial commissions, accident boards, departments of labor). As state workers compensation agencies contract with NCCI to utilize its Proof of Coverage (POC) program, the NCCI reporting of coverage data to those state workers compensation agencies eliminates the need for insurers to report coverage data directly to these agencies. (Insurers will be required by these agencies to submit coverage data, but insurers may satisfy this requirement by reporting coverage data directly to NCCI in place of the state agencies.) The coverage data submitted by NCCI to the state workers compensation agencies will be taken from the policy documents (Information Page, attached schedules, endorsements) submitted by insurers to NCCI. This is possible since the data required by these agencies is a subset of the data contained in the policy documents. The Policy Termination/Cancelation/Reinstatement Notice explained in this note is an additional policy document to be submitted by insurers to NCCI in order for NCCI to provide this data to the state agencies.

II. SUBMISSION OF POLICY TERMINATION/CANCELATION/REINSTATEMENT NOTICE--FORM WC 89 06 09
B This Notice must be submitted to NCCI for all policies with one or more states participating in NCCI's POC program as identified in Section V. NOTE: Virginia has its own Cancelation/Reinstatement Notice which is required to be filed directly with Virginia. A copy of the Virginia form is acceptable in lieu of this form to be sent to NCCI (insurers submitting cancelations and reinstatements electronically need not send either form to NCCI.) The submission conditions for the notice are as follows: 1. The policy is terminated, canceled or scheduled to be canceled or, where required, not renewed. or 2. The policy is reinstated after being canceled or scheduled to be canceled or nonrenewed and, as required in 1 above, this notice has previously been submitted to NCCI. or 3. The effective date for termination/cancelation is changed and, as required in 1 above, this notice has previously been submitted to NCCI. Insurers need not submit any forms, other than this Notice, to NCCI whenever one of the above conditions is applicable on policies with one or more states identified in Section V.

III. RELATIONSHIP OF POLICY TERMINATION/CANCELATION/REINSTATEMENT NOTICE TO COMPANY
REPORTING REQUIREMENTS FOR STATE WORKERS COMPENSATION AGENCIES (i.e., INDUSTRIAL COMMISSIONS, DEPARTMENTS OF LABOR, etc.) A. Definition of Single State and Multistate Policies A single state policy is defined, for the purpose of these rules, as a policy having only one of the states listed in Section V below set forth in Item 3.A. of the Information Page. A multistate policy is defined, for the purpose of these rules, as a policy having two or more of the states listed in Section V below set forth in Item 3.A. of the Information Page.

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© 1996 National Council on Compensation Insurance, Inc.

WC 89 06 09 B

STATE NOTES: POLICY TERMINATION/CANCELATION/REINSTATEMENT NOTICE Issued August 27, 1998 6th Reprint

B. Single State Policies
1. Single State Policies Covering a State in Which the POC Program Is in Effect Insurers are not required to submit any coverage data (i.e., notification of coverage, cancelation, etc.) directly to state workers compensation agencies for any policy providing coverage for a state listed in Section V below as of the date given for that state. Single State Policies Covering a State in Which the POC Program Is Not in Effect Insurers must continue to submit coverage data directly to state workers compensation agencies for any policy providing coverage for a state in which the POC program is not yet in effect. This will be any state not listed in Section V.

2.

C. Multistate Policies
Insurers are not required to submit any coverage data directly to any state workers compensation agency for a state covered by the policy and participating in the POC program as shown in Section V. Insurers must continue to report coverage data directly to state workers compensation agencies for a given state covered by the policy and not shown in Section V. A multistate policy, therefore, may result in insurers being required to submit coverage data directly to state workers compensation agencies for some states covered by the policy, but not for all states covered by the policy.

IV. REPORTING TIME FRAMES FOR FORM WC 89 06 09 B A. Terminations, Cancelations and Reinstatements
This notice must be received by NCCI on or before the number of days prior to the effective date of cancelation or termination, or for nonrenewal, prior to policy expiration date as specified in the Industrial/Workers Compensation Commission Administrative Rule and/or the statute of the state(s) covered by the policy. For multistate policies, it is the greatest number of days for any covered state that governs the reporting time frame. Reinstatement notices must be submitted as soon as the reinstatement is issued.

V. STATES AND DATES OF PARTICIPATION IN NCCI'S PROOF OF COVERAGE PROGRAM
POC State Alabama Colorado Connecticut District of Columbia Georgia Idaho Illinois Indiana Kansas Kentucky Louisiana Maryland Mississippi Missouri Montana Nebraska New Mexico Rhode Island South Carolina South Dakota Utah Vermont Virginia POC Date March 1, 1987 (Policy Effective Date) November 1, 1994 January 1, 1991 July 1, 1997 April 15, 1987 August 1, 1997 April 1, 1986 January 1, 1998 March 1, 1987 December 1, 1997 November 1, 1994 May 1, 1987 January 1, 1993 August 1, 1997 June 1, 1994 August 1, 1996 July 1, 1994 June 1, 1998 July 1, 1989 June 1, 1997 September 1, 1987 December 1, 1991 December 31, 1989

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© 1996 National Council on Compensation Insurance, Inc.

STATE NOTES: POLICY TERMINATION/CANCELATION/REINSTATEMENT NOTICE 6th Reprint Issued August 27, 1998

WC 89 06 09 B

Policy documents on hard copy should be sent as follows: U.S. Mail NCCI c/o First Image Data Acquisition Division P.O. Box 7369 London, KY 40742-7369 Policy documents on magnetic tape should be sent as follows: U.S. Mail NCCI-- Data Reporting Services P.O. Box 5049 Boca Raton, FL 33431-0849

Other Mailings NCCI c/o First Image Data Acquisition Division 1084 South Laurel Road London, KY 40741-9928

Other Mailings NCCI Data Management--Data Collection 750 Park of Commerce Drive Boca Raton, FL 33487

VI. MODIFICATION TO FORM WC 89 06 09 B
Insurers, other than those producing this notice by computer, must use this exactly as printed. This form is available from NCCI's Central Forms Program. Those insurers that produce this notice by computer may change the format of the form. The content of the form, including form number, must be duplicated exactly. An insurer may, however, only print the information and wording for the particular transaction being reported (e.g., cancelation wording only).

VII USE OF FORM WC 89 06 09 B AS A NOTICE OF CANCELATION TO THE INSURED .
Where permitted, insurers may use this notice to provide notice of cancelation to the insured as well as to NCCI. Many states have their own forms for this purpose. The use of this form as a cancelation notice to the insured is not mandatory. Insurers may use this form or their own company form at their option, subject to particular state requirements.

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© 1996 National Council on Compensation Insurance, Inc.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 3rd Reprint Issued July 1, 1996 POLICY TERMINATION/CANCELATION/REINSTATEMENT NOTICE Carrier Name/NCCI Carrier Code Insured's Name Federal ID No. Insured's Address

WC 89 06 09 B

Policy Number

Policy Effective Date

Policy Expiration Date

Termination/Cancelation/Nonrenewal The coverage provided by the policy number shown above is being _____ nonrenewed or _____ terminated/canceled, _____flat, _____ pro rata, or _____ short rate, effective ____________ 12:01 a.m. standard time at the insured's mailing address for the following reason(s):

Reinstatement The coverage provided by the policy number shown above and previously nonrenewed, canceled, or scheduled for cancelation is being reinstated effective _____________________ 12:01 a.m. standard time at the insured's mailing address.

Issue Date Issuing Office Producer's Name Date Stamp (For NCCI use only):

© 1996 National Council on Compensation Insurance, Inc.

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