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Workers' Comp Policy: Key Differences, Exclusions, and Procedures

Learn the distinctions between Parts 1 & 2 of workers' comp policy, coverage exclusions, claim procedures, injury classifications, loss components, and more.

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Workers' Comp Policy: Key Differences, Exclusions, and Procedures

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  1. What is the difference between Part 1 & 2 of the workers’ comp policy? • Part 1 is for liability other then worker’s benefits • Part 2 is for liability other then worker’s benefits • Part 3 is for liability other then worker’s benefits • There is only a part 1

  2. In your state, how does the limit of liability work for Part 2 and what is the minimum attachment point for the umbrella? • In most states it is unlimited • In most states they set a defined limit • In most states they set a defined limit and you have to have a minimum to have scheduled on umbrella • There is no limit

  3. What is a major exclusion under Part 2 of the workers’ comp that could be covered under the GL policy? • Contractual injury to an owner of a building. • Intentional act • Impaired property • Contractual injury to an employee.

  4. What do you do if you are not sure of these exposures; that is, they may develop during the policy period? • Schedule them on the policy • Schedule them at the time • Schedule them on an if any basis • Don’t worry they will be picked up

  5. What form does an employer have to file in order to make a claim? • C-8 • Incident Form • First Report of Injury • Worker’s comp web site form

  6. What form does an employer have to file in order to make a claim? • C-8 • Incident Form • First Report of Injury • Worker’s comp web site form

  7. What is the assumption of compensability? • Innocent until proven guilty • Guilty until proven innocent • Lost Wages • Medical payment for reason of an accident

  8. What is a schedule loss of use? • An amount of money for loss of a job • A PIR • Lost Wages • Medical payment for reason of an accident

  9. What is the maximum benefit for a back injury? • Depends on State • 10 Years • Depends on injury • No Maximum

  10. How are injuries classified? • Based on prognosis and ability to work • Determined by a Dr. • Determined by the comp board • Depends on the state

  11. What are the different components of an incurred loss? • Paid and Reserved • Expenses such as Lawyers • Only Paid • Paid, Reserved and Expenses

  12. What are reserves? How are they set and by whom? • Guesses set by underwriters at the time of the loss • Guesses set by adjusters at the time of the loss • Actuarial calculation set by underwriters at the time of the loss • Depends on the state

  13. How do you calculate a guaranteed cost policy premium? Provide an example, include all components. • Class Codes, Rates, discounts, assessments, mod and premium discount. • The carrier does this • Determined by the comp board • Depends on the state

  14. How does your state set rates? • NCCI • Open rating • Closed rating • Loss Cost State

  15. What is the purpose of a modification factor? • Charge more premiums • Charge less premium • Reward or penalize performance • Depends on the state

  16. Is your state an NCCI state? • Based on prognosis and ability to work • Determined by a Dr. • Determined by the comp board • Depends on the state

  17. What is a monopolistic state and what states are monopolistic? • The state handles comp • The state has one carrier • The carrier handles it for the state • There is no such thing

  18. Are heart attacks covered? • Based on prognosis and ability to work • Determined by a Dr. • Determined by the comp board • Depends on casual relationship to work.

  19. Is it covered if an employee is injured coming and going from work? • Based on prognosis and ability to work • Determined by a Dr. • Depends on facts • Depends on the state

  20. How do comp carriers deal with subcontracted employees? • They must have comp or your insured pays for them • They do not care • They charge you a lower rate • Depends on the county you are in

  21. How are companies classified? • On each job • On the type of business • Determined by the comp board • Depends on the state

  22. An employee in your home state is injured while traveling to another state. Which state law would apply to the employee? • Where they live • Where there home office is • What ever they want • Depends on the state

  23. An employee has a heart attack at work, is it covered? • Based on prognosis and ability to work • Determined by a Dr. • Determined by the comp board • Depends on the state

  24. How does a wrap up affect an Insured’s Mod? • Same as any other job • Not at all • Determined by the comp board • Depends on the state

  25. Two employees are fooling around at work and one is injured. Is the injury covered? • Yes if it happened at work • Determined by a Dr. • Determined by the comp board • No

  26. Explain how a back injury is finalized in your state as well as what conditions must be met before it is finalized. Compare and contrast this claim to carpal tunnel. • Based on prognosis and ability to work • Determined by a Dr. • Determined by the comp board • Depends on the state

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