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

Authorization Form for Direct Deposit/Payment of Commission Checks
This form gives us the information necessary to deposit commission payments directly into the agency’s bank account.

Authorization Form for Electronic Correspondence
This form gives us 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 FUBA Workers’ Comp 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 in the construction industry.

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

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

FCBI Supplemental Application and Membership Participation Agreement
This form is the supplemental application­ policyholders are required to sign at binding.

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).

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

Waiver of Subrogation Endorsement Instructions
This document contains instructions on how to apply for a waiver of subrogation endorsement.­


Policyholder Resources & Documents

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

A Contractors Guide to Workers’ Compensation (Spanish)
This brochure explains Florida contractors’ responsibilities under the workers’ comp law in Spanish.

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 those ­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 the Florida workers’ compensation law.

Ladder and Scaffold Training Materials
These training materials teach employees to 1) understand how to choose, inspect, and use ladders correctly and 2) be aware of general safety requirements for scaffold users.

Ladder and Scaffold Training Materials – Spanish Version
These training materials teach employees to 1) understand how to choose, inspect, and use ladders correctly and 2) be aware of general safety requirements for scaffold users in Spanish.

Non-Compliance Violations
This website explains the penalties for not complying 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.

Work Related Injuries Reporting Wall Card
This is a wall card policyholders should post near their workers’ compensation poster ­with instructions on ­how to file a workers’ compensation claim in both English and Spanish.