Proof Of Coverage Notice {D-48}

STATE NOTES: PROOF OF COVERAGE NOTICE Issued May 15, 1997 WC 89 06 20 C Standard I. BACKGROUND The Proof of Coverage (POC) Notice was developed to be used in certain states, but only if policies cannot be issued to be received by the National Council on Compensation Insurance, Inc. (NCCI) within the coverage notice requirements of the states. Additionally, it should only be sent to NCCI to cancel a previously submitted POC Notice when the policy has not been issued. II. SUBMISSION OF PROOF OF COVERAGE NOTICE--WC 89 06 20 C This Notice must be submitted to NCCI for all policies which will not be received by NCCI within the states coverage notice requirement as shown in Section III. This form is not a substitute for the policy Information Page (WC 00 00 01 A), which when issued should continue to be submitted to NCCI. When the Information Page is received by NCCI, it will replace the POC Notice, but keep the original receive date of the POC Notice. In order for this match to occur, the Policy Number, Carrier Code and Policy Effctive Date must be the same on the policy Information Page as was reported on the POC Notice. If the policy Information Page is to be or is issued with the Policy Number, Carrier Code and/or Policy Effective Date different than that reported on the POC Notice, use the POC Notice form, Change/Deletion Notice section, to change the data element(s) that is different. This is required to ensure that there is a match between the POC Notice and the policy Information Page and to maintain the original coverage notification date from the POC Notice. Reminder: The policy Information Page data will completely replace the information provided on the POC Notice except for the receipt date of original coverage notification. If coverage is to be canceled and the policy Information Page has not been issued, submit the POC Notice indicating cancelation. The top portion of the form must be identical to that provided on the original POC Notice. If the policy coverage is to be canceled and the policy Information Page has been issued, the Policy Termination/ Cancelation/Reinstatement Notice (WC 89 06 09 B) must be used to cancel the policy. If information on the POC Notice needs to be changed, complete the top portion of the form as originally submitted and complete only the item(s) to be changed in the Change/Delete Notice section of the form. All changes are as of the Policy Effective Date. The Delete Proof of Coverage Notice should be used only if the Proof of Coverage Notice was issued in error. If the Proof of Coverage Notice was issued legitimately and is no longer required, use the Termination/Cancelation section of the form. Mail all POC Notice forms as follows: U.S. Mail NCCI, Inc. c/o First Image Data Acquisition Division P.O. Box 7369 London, KY 40742-7369 Other Acceptable Means of Delivery * NCCI, Inc. c/o First Image Data Acquisition Division 1084 South Laurel Road London, KY 40742-9928 * "Other Acceptable Means of Delivery" include delivery services such as but not limited to Federal Express, UPS, etc. 1 of 2 D-48 © 1997 National Council on Compensation Insurance, Inc. American LegalNet, Inc. www.USCourtForms.com WC 89 06 20 C Standard STATE NOTES: PROOF OF COVERAGE NOTICE Issued May 15, 1997 III. STATES THAT ACCEPT THE PROOF OF COVERAGE NOTICE Number of Days After Policy Effective Date Policy Must Be Received by NCCI 30 30 30 State Colorado Maryland South Carolina POC Effective Date November 1, 1994 October 1, 1991 July 1, 1989 POC Notice Implementation Date April 1, 1997 October 1, 1991 July 1, 1989 IV. MODIFICATION TO FORM WC 89 06 20 C Data providers, other than those producing this notice electronically, must use this form exactly as printed. This form is available from NCCI's Central Forms Program. Data providers producing this form electronically may change the format of the form. The contents of the form, including the form number, must be duplicated exactly. These data providers may, however, print only the information and wording for the particular transaction being reported (e.g., cancelation wording only [entire top portion of form is required]). V. USE OF FORM WC 89 06 20 C AS A NOTICE OF CANCELATION TO THE INSURED Where permitted, data providers may use this notice to provide notice of cancelation to the insured as well as to NCCI. The use of this form as a cancelation notice to the insured is not mandatory. Data providers may use this form or their own company form at their option, subject to particular state requirements. 2 of 2 D-48 © 1997 National Council on Compensation Insurance, Inc. American LegalNet, Inc. www.USCourtForms.com WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Issued May 15, 1997 PROOF OF COVERAGE NOTICE Insured's Primary Name Insured's Primary Address PROOF OF COVERAGE NOTICE WC 89 06 20 C Federal ID No. Carrier Name Issuing Office NCCI Carrier Code Policy Number Policy Effective Date Policy Expiration Date State(s) Covered Issue Date TERMINATION/CANCELATION The coverage provided by the policy number shown above is being terminated/canceled effective _____ 12:01 a.m. standard time at the insured's mailing address for the following reason(s): Issue Date CHANGE/DELETION NOTICE The coverage information indicated above is being changed. The changes are as follows: Revised Insured's Primary Name Revised Insured's Primary Address Revised Federal ID No. Revised NCCI Carrier Code Revised Policy Number Revised Policy Effective Date Revised Policy Expiration Date Revised State(s) Covered Delete Proof of Coverage Notice Issue Date © 1997 National Council on Compensation Insurance, Inc. D-48 American LegalNet, Inc. www.USCourtForms.com