MS Forms & Fees

NOTICE

Important Information Regarding Mississippi Workers Compensation Assigned Risk Applications

Effective May 7th, NCCI began processing workers compensation assigned risk applications for Mississippi. Click here for details

ACORD forms

v For best results, always use the most current ACORD 130 and ACORD 133 forms available. Forms may be obtained from ACORD by calling 800-444-3341.

Additional Fees

v Include the fees shown below when computing premium for applications submitted to the MS Pool.

Waivers	$250 per waiver (no blanket waiver)
Experience Mod	Apply NCCI mod
EL Limits ($1,000's) $100/500/100 $500/500/500 $1,000/1,000/1 ,000	no charge 1.7% of premium ($100 minimum) 2.8% of premium ($150 minimum)
Terriorism/Catastrophy TRIA DMEC	$0.03 per $100 of payroll $0.01 per $100 of payroll
Expense Constant	$250

Notes: Additional assigned risk surcharge - None (already included in rates)

Premium Discount - None

Payroll

Partners and Sole Proprietors	$32,000 (effective 3/1/2007)
Executive Officers	$5,200 - $98,800

Deposit Premium & Payments

Total Premium	Deposit Premium	Payments
Under $5,000	100%	n/a
$5,000 - 10,000	75%	Balance due in 6 months
$10,000 - 25,000	50%	Balance due in 3 quarterly payments
$25,000 and over	25%	Balance due in 9 monthly payments
Prem. Financed	Total Prem Due	n/a

Rates

v Click here for current MS WC Assigned Risk Rates

Out of State Contractors

v Out of state contractors must include on the application a valid physical address and telephone number for contact purposes once operations in Mississippi expire.

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