Forms Library
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General Forms and Applications
- A Contractor's Guide to Workers' Comp (English)
This brochure is helpful for our construction members desigend to assist contractors in following Florida's workers' comp requirements. Available in Spanish.
- Agent/Broker of Record ACORD Form 36 (1/98)
This form is used when a policyholder changes their current agent or broker of record. Policyholders should contact their new agent for assistance in completing this form.
- Authorization Form for Direct Deposit/Payment of Commission Checks (Optional)
This form gives us the information necessary to deposit commission payments directly into the agency's bank account.
- Authorization Form for Electronic Correspondence (Required)
This form gives us the information necessary to send regular agency correspondence, such as new and renewal policies, cancellations, reinstatements and endorsements, via email.
- Cancellation Request/Policy Release ACORD Form 35
This form is used when a policyholder is interested in terminating their coverage. Policyholders should contact their new agent for assistance in completing this form.
- 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.
- Exemption Application - DWC 250
This form is used to apply for an exemption from workers' compensation insurance and needs to be filed with the Division of Workers' Compensation.
- Instructions for Completing Exemption Application - DWC 250-I
This form includes instructions on how to complete an exemption application.
- FCBI Supplemental Application and Membership Participation Agreement - UPDATED
This form is the updated, one-page, black and white supplemental application insureds are required to sign at binding.
- Final Audit Dispute Form
This form must be completed by the policyholder in order to dispute a final premium audit.
- Final Audit Reopen Form
This form must be completed by the policyholder in order to have a final premium audit reopened.
- First Report of Injury Form
This form is used to report claims and collect pertinent employer, employee, and accident information. Completed forms may be submitted via email to our Claims Department to claimreporting@usis-tpa.com.
- 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).
- Florida Workers' Compensation Application ACORD Form 130-FL (2002/07)
Approved agents must use this form to request a quote from FUBA Workers' Comp.
- Florida Contracting Classification Premium Adjustment Program Application 2010 (FCCPAP)
Policyholders can apply for a premium adjustment based on their contracting classification.
- Form I-9
This form helps ensure that all employees are eligible to work in the United States and should be completed before employees begin working. All employers in the United States are responsible for collecting a completed I-9 form for each individual they hire.
- Form I-9 - Spanish
The same form as above in Spanish.
- Monthly Change Sheet
This form is used to inform FUBA Workers' Comp of changes to policies. Policyholders should contact their agent for assistance in completing this form.
- NCCI Drug Free Premium Credit Application
Policyholders can apply for a premium credit based on their drug-free policy. An application and copy of the program are required to receive credit on the policy.
- NCCI Safety Premium Credit Application
Policyholders can apply for a premium credit based on their safety program. An application and copy of the program are required to receive credit on the policy.
- Notice of Election of Coverage - DWC 251
This form is used by non-construction partners, LLC members and sole proprietors who elect to be covered by workers' compensation. This form needs to be filed with the Division of Workers' Compensation.
- Recently Written NCCI Class Codes
This is a list of NCCI class codes most recently written by FUBA Workers' Comp, however it is not a listing of all eligible class codes.
- Revocation of Election of Coverage - DWC 251-R
This form is used by non-construction partners, LLC members and sole proprietors to revoke workers' compensation coverage. This form needs to be filed with the Division of Workers' Compensation.
- Revocation Election to be Exempt - DWC 250-R
This form is used to revoke a current exemption from workers' compensation. This form needs to be filed with the Division of Workers' Compensation.
- Sample Job Application
Completion and retention of job applications for all employees is strongly encouraged. In addition to being a smart business practice, it may also assist employers in the event of a workplace injury or fraud. A job application and reference check should be completed before employees begin working.
- Statement of No Loss ACORD 37 (1/96)
This form must be submitted with a quote request if the business has never been covered by workers' compensation. It is also used if a policyholder has a lapse in coverage.
- Waiver of Subrogation Application & Instructions
This form must be used when applying for a Waiver of Subrogation from FUBA Workers' Comp. Instructions are included.
- Workers' Comp Solutions for Florida Businesses
This brochure is designed to help agents and policyholders learn more about FUBA Workers' Comp and our products and services.
To obtain a copy of the most recent class code rates online, please visit NCCI's website at http://www.ncci.com/.
Agency Forms and Applications
If you are a licensed agency currently operating in the state of Florida and are interested in becoming an approved agency with FUBA Workers' Comp, please fill out the following required documents in order to be considered for approval:
Fax or email the completed forms to:
Marketing/Sales Fax: (850) 681-0765
Email: fubawc@fubaworkerscomp.com
For more information, please visit the Become An Agent section of our website.
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