Date: Completed application due at The National Council by: To: Re: Illinois Contracting Classification Premium Adjustment Program (ILCCPAP) Confidential Workers Compensation Premium Credit Application The Illinois Contracting Classification Premium Adjustment Program is applicable to qualifying employers engaged in contracting operations and is applicable to policies with effective dates on or after April 1, 1994. In order to qualify for the program, your policy must have more than 50% of manual premium attributable to one or more contracting classifications (as designated by the program) for Illinois operations only and have a calculated experience modification of less than or equal to 1.00. A special premium calculation, which may result in a premium credit for you, will be based on an average hourly wage scale for each classification of contracting operations in Illinois. In order that your premium may be correctly established, please return completed premium credit application as set forth on the attached form (WC-40) to: National Council on Compensation Insurance, Inc. Customer Service Center 901 Penninsula Corporate Circle Boca Raton, FL 33431-0998 ATTN: Experience Rating – Illinois Fax: (561) 893-1191 NCCI will advise us of any premium credit applicable. If NCCI does not receive this application within 180 days after policy inception, your premium calculation will not reflect any possible premium credit. In addition, this application will be returned unprocessed if not completed in its entirety. The information supplied on this application will be confidential. For each applicable classification (both contracting and non-contracting) covering your company’s operations in the state of Illinois, report the total Illinois payroll (excluding overtime premium pay, vacation pay, unanticipated bonuses, pay for any exempt sole proprietor, partner, or officer, Davis Bacon Fringe Benefits you pay into any ERISA qualified third party pension plan and other Illinois exclusions) and the corresponding total number of hours worked, for the third calendar quarter (July, August, September) of the year preceding your policy effective date as reported to taxing authorities. Note #1 If you did not engage in contracting operations during the third quarter, the requested information to be provided should then be for the last complete calendar quarter prior to the effective date of your workers compensation policy. Do not include payroll from any state other than Illinois. Note #2 If you have just begun operations in Illinois (no prior operations), and have a calculated experience modification equal to 1.00 or less, submit the requested information for the first complete calendar quarter following the effective date of your workers compensation policy when available, excluding any payroll from any state other than Illinois. Note #3 In the absence of specific records for salaried employees, you should assume that each individual worked forty (40) hours per week. Payroll for non-exempt partners, sole proprietors and officers subject to contracting classifications will be subject to appropriate Basic Manual minimums and maximums or limitations. Do not include payroll for persons not covered by the policy such as exempt partners, sole proprietors and officers. Note #4 If you do not have a calculated experience modification equal to 1.00 or less and do not have more than 50% of Illinois manual premium attributable to one or more qualifying contracting classifications, do not complete and submit this application as you are not qualified for this credit program. You must preserve your payroll records which formed the basis for this declaration as we will be required to verify the reported information in order for any premium credit to be applied. Thank you for your cooperation. Sincerely, WC-39 (03/06) Illinois Contracting Classification Premium Adjustment Program (ILCCPAP) Confidential Workers Compensation Premium Credit Application Section One Insured: _______________________________________________ Carrier: _________________________________________________ Policy number:___________________________________________ Period: from: ________________ to: _________________________ 1. Is this business experience rated at 1.00 or less? • Yes • No If yes, provide NCCI risk ID#: ______________________________________________________________________________________ If no, please do not complete and submit the application. 2. Did you have operations in Illinois during the third quarter of the prior calendar year? • Yes • No If yes, in Section Two below, submit information for the third calendar quarter (July, August, September) of the year preceding the policy effective date as reported to taxing authorities. If no, in Section Two below, submit information for the last completed quarter prior to the effective date of your workers compensation policy. (Note: If you have just begun operations in Illinois, submit information for the first complete calendar quarter following the effective date of your workers compensation policy.) Notice: Unless Code(s), total wages paid, total hours worked, calendar quarter reported are indicated and application is signed, the application will be returned unprocessed. Contact your agent or carrier if assistance is desired. Section Two Classifications Code Total Illinois Wages Paid * Total Illinois Hours Worked** Eligible contracting classifications: Non-contracting classifications: * Excluding overtime premium pay – if an employee makes $20/hour and is paid time and one-half ($30), only report the payroll based upon the $20/hour. Also, excluding the salaries and hours worked of any exempted sole proprietor, partner or officer. ** Including overtime hours. Section Three The above is based on actual wages (excluding overtime premium pay, pay for any exempt sole proprietor, partner, or officer, Davis Bacon Fringe Benefits, and other Illinois exclusions) and hours worked as reflected in our payroll records for the complete calendar quarter ending _________. Signature: ______________________________________________ Position: ___________________ Date: _______________________ WC-40 (03/06) “Contracting Classifications” are those classifications subjected to the following code numbers: 0042 5020 5102 5215 5437 5491 5610 6017 6216 6251 7538 9549 0050 5022 5146 5221 5443 5506 5645 6018 6217 6252 7601 9553 1322 5037 5160 5222 5445 5507 5651 6045 6229 6260 7855 3365 5040 5183 5223 5462 5508 5703 6204 6233 6306 8227 3719 5057 5188 5348 5474 5538 5705 6206 6235 6319 9529 3724 5059 5190 5402 5479 5551 6003 6213 6236 6325 9534 3726 5069 5213 5403 5480 5606 6005 6214 6237 6400 9545 WC-40 (03/06)