Application for Coverage
1. Complete Application
A complete application is required (ACORD 130 & ACORD 133). Submit applications by:
Regular Mail
Travelers – MO Workers' Comp Plan
P.O. Box 5600
Hartford, CT 06102-5600
Overnight Mail
Missouri Workers' Compensation Plan
Document Management – RMD
300 Windsor St.
Hartford, CT 06120
Fax
1 (844) 335-7825
Applicants must include the original application with an original signature of an officer/owner along with a deposit check made payable to Travelers.
If the following information is missing from the application, the requested effective date may be impacted and the application and deposit may be returned:
- Physical location in Missouri.
- Original signature of the officer/owner and the insurance producer.
- Company’s phone number.
- Company’s Federal Employer Identification Number (FEIN).
- Rating information: Class code(s); estimated annual remuneration/payroll, rate; and estimated annual manual premium.
- Premium calculation (Missouri Quick Quote tool may be used to help calculate the premium – attaching a Quick Quote calculation is recommended but not required)
- Prior carrier information/loss history.
- Nature of business/description of operations.
- Note: 2 voluntary market carrier declinations are required to be eligible under the Plan.
2. Payroll Verification
- A copy of the employer's latest filed federal employer 941, 941E, 942 or 943 form, or
- Equivalent federal or state required verifiable current payroll record, such as an unemployment wage report.
3. Supporting Documents
Sole proprietors and partners are considered employers, not employees, and are not covered by your policy. Sole proprietors and partners can be added to the policy by endorsement. Payroll for all sole proprietors and partners is currently assessed at $40,600 per year. If partners or sole proprietors elect coverage, payroll must be included, and a letter stating clear intent must be attached to the application.
Corporate officers are considered employees of the corporation and must be covered.
Limited liability company members are covered by your workers' compensation policy unless they specifically state they do not wish to be covered, using a special endorsement to your policy.
Limited liability corporation (LLC) members must submit a signed rejection form to be excluded.
4. Deposit
A certified, cashier's, insured's or agency check payable to Travelers should be forwarded with the completed application to:
Regular Mail
Missouri Workers' Compensation Plan
P.O. Box 5600
Hartford, CT 06102-5600
Overnight Mail
Missouri Workers' Compensation Plan
Document Management - RMD
300 Windsor St.
Hartford, CT 06120
Pay by Phone
800-842-9346
Pay Plan Options
| Estimated annual premium | Payment basis | Minimum deposit percentage | Additional payments during year |
|---|---|---|---|
| Under $2,500 | Annual | 100% of annual | None |
| $2,501 - $10,000 | Quarterly | 40% of annual | Three* |
| Over $10,000 | Monthly | 30% of annual | Nine* |
| If the employer’s estimated annual premium equals or exceeds $250,000, they qualify for the Mandatory Missouri Loss Sensitive Rating Plan. An additional 20 percent deposit is required by the plan. | *$10 service charge per installment. | ||
Determining Effective Date
- For all employers other than those formerly self-insured, coverage will be bound at 12:01 a.m. on the first day following the U.S. Postal Service postmark time and date on the envelope in which the application is mailed, including the estimated annual or deposit premium, or the expiration of existing coverage, whichever is later.
- Note: For effective date determination, a postage meter (device that generates indicia imprinted on or affixed to mail pieces to show prepayment of postage) mark is not considered to be a postmark.
- If there is no U.S. postmark, coverage will be effective 12:01 a.m. of the date of receipt by the contract carrier unless a later date is requested.
- Applications hand delivered to the contract carrier will be effective as of 12:01 a.m. the date following receipt by the contract carrier unless a later date is requested.
- The contract carrier will accept an application by fax. Coverage will be bound within 24 hours after the fax receipt date of the completed application if the premium is received within five days.
- For employers formerly self-insured, coverage will be bound at 12:01 a.m. not later than 60 days following the U.S. postmark time and date on the envelope in which the application is mailed including the estimated annual or deposit premium, or the expiration of existing coverage, whichever is later.
- If there is no U.S. postmark, coverage will be effective 12:01 a.m. not later than 60 days following the date of receipt by the contract carrier unless a later date is requested.
- Applications that are hand delivered to the contract carrier will be effective 12:01 a.m. not later than 60 days following the date of receipt by the contract carrier, unless a later date is requested.
Pricing
Policies will be issued utilizing the classifications, forms, rates and rating data included in the contract carrier's Request for Proposal (RFP) response or as otherwise approved by the director. NCCI rating plans will be utilized. Since various programs such as Assigned Risk Adjustments, Rate Differentials, Surcharges and Missouri Injury Management Program have been approved, we suggest you verify the premium calculations with the contract carrier.
| Premium discount | Not applicable | ||
|---|---|---|---|
| Expense constant | Refer to miscellaneous values for expense constant | 100% of annual | None |
| Increased EL limits | Standard limits | $100/$100/$500 | No premium charge |
| Increased limits | $500/$500/$500 | (0.8% of premium) | |
| $1,000/$1,000/$1,000 | (1.1% of premium) | ||
| Safety Program | Missouri Injury Management Program (MIMP) | ||
| Merit Rating | Not applicable | ||
| Retro Rating Plan | Missouri Loss Sensitive Rating Plan (LSRP) | ||
| Assigned Risk Adjustment Program (ARAP) | Applicable – maximum factor 25% | ||
| Contracting Classification Premium Adjustment Program (CCPAP | Applicable | ||
| Terrorism Risk Insurance Act (TRIA) | Applicable: Surcharge is based on payroll | Payroll /100 x TRIA factor. Refer to miscellaneous values of rate pages for TRIA factor | |