Forms Library

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General Forms and Applications

• 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
  This form gives us the information needed to deposit commission payments directly into the agency's bank account.
• Authorization Form for Electronic Correspondence
  This form gives us the information needed 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.
• 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.
• 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 2008 (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.
• 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.
• NCCI Safety Premium Credit Application
  Policyholders can apply for a premium credit based on their safety program.
• 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 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
  This form must be used when applying for a Waiver of Subrogation from FUBA Workers' Comp.
• Waiver of Subrogation Application Instructions
  These are instructions for filling out a Waiver of Subrogation Application.

Please note:

(1) The FCBI Supplemental Application and Membership Participation Agreement is not available online.  This form must be an original and come from our office.  To obtain copies, please email the Agency Services Department or call 888-262-4483 and we will be happy to mail you a supply.

(2) We no longer have NCCI rates online.  You may visit their website at www.ncci.com to obtain a copy of the most recent class code rates.

Agency Forms and Applications

If you are an agency seeking to write business with FUBA Workers' Comp, please print and fill out the following forms, include an $85 check made payable to FUBA, and mail to FUBA Workers' Comp, Attention: Marketing Department, Post Office Box 1303, Tallahassee, FL 32302-1303. In addition to the forms below, please be sure to include copies of 220 licenses and proof of $1 million of Errors and Ommisions (E&O) insurance.

• Agency Application for Approval
• Agency Agreement
• W-9
• Florida United Businesses Association (FUBA) Application

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