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FORMS & ENDORSEMENTS

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Form Title (click PDF icon to open)
Acceptance of Bureau Membership and Designation
Acceptance of New Jersey Workers Compensation Insurance Plan
New Jersey Workers Compensation Insurance Plan Instructions and Rules ACORD 132NJ (9/2015)
New Jersey Workers Compensation Insurance Plan Application For Designation Of An Insurance Company ACORD 133NJ (9/2015)
New Jersey Workers Compensation Insurance Plan Notice Of Election - Proprietors and Partners ACORD 134NJ (9/2015)
New Jersey Workers Compensation Insurance Plan Client Supplemental Employee Leasing Application ACORD 135NJ (9/2015)
New Jersey Workers Compensation Insurance Plan Truckers Supplemental Application ACORD 136NJ (9/2015)
Posting Notice Form 16 NJ (4/2000)
Large Risk - Large Deductible Program Notice Of Election (Effective 7/1/06) Form NJ LR-LD (6th Rev)
New Jersey Notice Of Election - Retrospective Rating Form NJRR-1 (8th Rev)
New Jersey Notice Of Election - Retrospective Rating (Effective 1/1/16) Form NJRR-2
New Jersey Notice Of Election - Proprietors and Partners Workers Compensation and Employers Liability Insurance Form PP-1B
Application for An Approved Managed Care Program Premium Reduction
Experience Rating Data Form XM1-2014
Primary Unit Statistical Reporting Form USR-ASWG Form A
New Jersey CRIB Hard Copy Transmittal Letter Form TL-1
New Jersey - Letter of Transmittal Form S-31NJ
Cancellation Form Form 116-B
Reinstatement Form Form 117-A
Carrier Administrator Application Form
Experience Rating Data Worksheet Order Form
NJCRIB Experience Rating Data and USR Account Form
Unit Statistical Report Request Order Form
Endorsement Title (click PDF icon to open)
Information Page WC 00 00 01 A
Defense Base Act Coverage Endorsement WC 00 01 01 A
Federal Employers Liability Act Coverage Endorsement WC 00 01 04 A
Longshore and Harbor Workers Compensation Act Coverage Endorsement WC 00 01 06 A
Outer Continental Shelf Lands Act Coverage Endorsement WC 00 01 09 C
Maritime Coverage Endorsement WC 00 02 01 B
Voluntary Compensation Maritime Coverage Endorsement WC 00 02 03
Alternate Employer Endorsement WC 00 03 01 A
Designated Workplaces Endorsement WC 00 03 02
Insurance Company as Insured Endorsement WC 00 03 04
Joint Venture as Insured Endorsement WC 00 03 05
Rural Utilities Service Endorsement WC 00 03 09 B
Experience Rating Modification Factor Endorsement WC 00 04 03
Pending Rate Change Endorsement WC 00 04 04
Policy Period Endorsement WC 00 04 05
Rate Change Endorsement WC 00 04 07
Premium Due Date Endorsement WC 00 04 19
Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement WC 00 04 21 D
Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement WC 00 04 22 B
Audit Noncompliance Charge Endorsement WC 00 04 24
Experience Rating Modification Factor Revision Endorsement WC 00 04 25
Retrospective Rating Plan Premium Endorsement One Year Plan WC 00 05 03 C
Retrospective Rating Plan Premium Endorsement Three Year Plan WC 00 05 04 C
Retrospective Rating Plan Premium Endorsement Wrap-Up Construction Project WC 00 05 05 C
Retrospective Premium Endorsement Aviation Exclusion WC 00 05 08
Retrospective Premium Endorsement Changes WC 00 05 09 A
Retrospective Rating Plan Premium Endorsement Non-Ratable Catastrophe Element or Surcharge WC 00 05 10 B
Retrospective Premium Endorsement Short Form WC 00 05 11
Retrospective Rating Plan Premium Endorsement Flexibility Options WC 00 05 15 A
Retrospective Rating Plan Premium Endorsement Large Risk Alternative Rating Option (LRARO) WC 00 05 16
New Jersey Voluntary Compensation Federal Employers Liability Act Coverage Endorsement WC 29 01 01
New Jersey Workers Compensation and Employers Liability Coverage for Residence Employees Endorsement WC 29 03 02 A
New Jersey Employee Leasing Labor Contractor Endorsement WC 29 03 03
New Jersey Employee Leasing Client Exclusion Endorsement WC 29 03 04 A
New Jersey Employee Leasing Labor Contractor Exclusion Endorsement WC 29 03 05 A
New Jersey Part Two Employers Liability Endorsement WC 29 03 06 B
New Jersey Sole Proprietors and Partners Coverage Endorsement WC 29 03 07
New Jersey Limited Other States Insurance Endorsement WC 29 03 09 A
New Jersey Workers Compensation Insurance Plan Eligibility Endorsement WC 29 03 10
New Jersey Employee Leasing Client Endorsement WC 29 03 11
New Jersey Notice of Cancellation or Material Coverage Change to Designated Governmental Entity Endorsement WC 29 03 12
New Jersey Approved Managed Care Program Endorsement WC 29 04 09 A
New Jersey Construction Classification Premium Adjustment Endorsement WC 29 04 10
New Jersey Premium Discount Endorsement Schedule Y WC 29 04 11 E
New Jersey Premium Discount Schedule X WC 29 04 12 B
New Jersey Retrospective Premium Endorsement Part Two-Employers Liability Insurance Excess Exclusion WC 29 05 09 C
New Jersey Large Risk - Large Deductible Endorsement WC 29 06 01 A
New Jersey Large Risk - Large Deductible Retrospective Adjustment Endorsement WC 29 06 02 B
New Jersey Participating Provision Endorsement WC 29 06 03
New Jersey Large Risk - Large Deductible Aggregate Limit Endorsement WC 29 06 04
New Jersey Large Risk - Large Deductible Endorsement Per Person Basis WC 29 06 05
Policy Information Page Endorsement WC 89 06 00 B