Resources & Documents

[All ACORD forms are located in a secure, password protected section of our website.  Agents must log-in to our Agent Portal in order to view and download these forms.]

Agent Resources & Documents

(Documents are listed in alphabetical order.)

Authorization for Direct Deposit of Agency Commission
This form gives FUBA Workers’ Comp the information necessary to deposit commission payments directly into the agency’s bank account.

Authorization for Electronic Correspondence
This form gives FUBA Workers’ Comp 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 us of changes in business ownership.­ Policyholders should contact their agent for assistance in completing this form.

Construction Codes List
The Florida Division of Workers’ Compensation’s official list of NCCI class codes that the State of Florida considers to be included within the construction industry.

Construction Questionnaire
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.

Exemptions At-A-Glance
With all the recent changes to Florida workers’ compensation exemption laws, and in order to have all pertinent information in one place, we have created this handy “Exemptions At-A-Glance” reference guide.

Exemptions At-A-Glance – Spanish
With all the recent changes to Florida workers’ compensation exemption laws, and in order to have all pertinent information in one place, we have created this handy Spanish-language “Exemptions At-A-Glance” reference guide.

Florida Contracting Classification Premium Adjustment Program Application 2010 (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).

Florida United Businesses Association (FUBA) Application
This application is used by employers and agents to join our sponsoring trade association, Florida United Businesses Association (FUBA). Membership in FUBA is required to obtain A- rated workers’ compensation coverage through FUBA Workers’ Comp and to receive numerous other association benefits.

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 a copy of the program are required in order to receive credit on the policy.


Policyholder Resources & Documents

(Documents are listed in alphabetical order.)

A Contractors Guide to Workers’ Compensation
This brochure explains a Florida contractor’s responsibilities under the workers’ comp law.

A Contractors Guide to Workers’ Compensation (Spanish)
This Spanish-language brochure explains a Florida contractor’s responsibilities under the workers’ comp law.

Construction Policy Tracking Database
This is an online tool that provides information to contractors regarding the coverage status of the contractors they use.

Exemption Information

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 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 Florida workers’ compensation laws.

Important Workers’ Compensation Information for Florida’s Employers
This informative brochure contains helpful information on workers’ compensation insurance from the Florida Department of Financial Services, Division of Workers’ Compensation.

Important Workers’ Compensation Information for Florida’s Employers – Spanish
This informative Spanish-language brochure contains helpful information on workers’ compensation insurance from the Florida Department of Financial Services, Division of Workers’ Compensation.

Join the Battle Against Workers’ Compensation Fraud
This brochure from the Florida Department of Financial Services, Division of Investigative & Forensic Services explains the different types of workers’ compensation insurance fraud and what to do if you suspect it.

Non-Compliance Violations
This website explains the penalties for failure to comply with Florida’s workers’ compensation coverage requirements.

Payroll Verification Audit Dispute Form
This form must be completed by the policyholder in order to dispute a premium audit.

Payroll Verification Audit Reopen Form
This form must be completed by the policyholder in order to have a premium audit reopened.

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.

Quarterly Self-Reporting Form
This is the required form used by policyholders enrolled in our Quarterly Self-Reporting (QSR) program.

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.