Coverage description
A National Council on Compensation Insurance (NCCI) standard form. It extends Part Two employers liability coverage to work subject to the Federal Employers' Liability Act in the states in its schedule, with its own each accident and disease aggregate limits, while Part One does not apply in those states.
Updated
What the form says
Key clauses from edition A, the latest revision, quoted as filed.
“If any state is named in Item 2 of the Schedule, Part Two (Employers Liability Insurance) applies in that state to work subject to the Federal Employers’ Liability Act”
WC 00 01 04 A
Where the coverage applies. Employers liability for work under the Act is granted state by state. Only the states entered in Item 2 of the schedule are treated as though they were listed in Item 3.A.
“Part One (Workers Compensation Insurance) does not apply in a state shown in the Schedule.”
WC 00 01 04 A
No workers compensation in those states. The endorsement provides employers liability only. Statutory workers compensation benefits are not paid under this policy in a scheduled state.
“The limit applies separately to bodily injury by disease arising out of work in each state shown in Item 3.A. of the Information Page or in the Schedule.”
WC 00 01 04 A
How the disease limit is applied. The endorsement replaces the Part Two limits with two limits entered in its schedule, each accident and disease aggregate. The disease aggregate is not shared across states: each Item 3.A or scheduled state has its own.
“Part Two (Employers Liability Insurance), C. Exclusions, exclusion 9, does not apply to work subject to the Federal Employers’ Liability Act.”
WC 00 01 04 A · New in this edition
The policy's exclusion for this work is lifted. Part Two exclusion 9 of the policy removes employers liability for work under the Act. Revision A adds this sentence so that exclusion does not cut back the coverage the endorsement grants.
How the form has changed
1 change across 1 revision, newest first. Each edition is compared with the one before it, using wording from filed copies.
Edition A
Compared with the original editionLatest editionRevision A adds a sentence stating that Part Two exclusion 9, the policy's exclusion for work under the Act, does not apply to work under the Act. The rest of the wording and the two-limit schedule are unchanged.
Original edition
Not in this edition
Edition A
“Part Two (Employers Liability Insurance), C. Exclusions, exclusion 9, does not apply to work subject to the Federal Employers’ Liability Act.”
Editions
Revision letters as filed, newest first. Filing counts include every state submission that lists the edition.
| Edition | Filings | Companies | States | Filed | Document |
|---|---|---|---|---|---|
| ALatest | 113 | 76 | 15 | Jan 2022 to Nov 2026 | View PDF |
| Original | 4 | 9 | 2 | Feb 2023 to Sep 2026 | View PDF |
Where filings record what this form replaced, they name other forms N/A. Only some filings record replacements.
What the filings show
- Edition in use: in the past 12 months, 42 companies filed edition A and 4 companies filed the original edition.
- WC 00 01 06 (Longshoremen's and Harbor Workers' Compensation Act Coverage Endorsement) is filed alongside it most often, in 109 of the same filings (94%).
Filed under
Data from admitted P&C filings with state insurance departments, submitted Nov 2021 to Nov 2026, excluding withdrawn and rejected filings. One filing can cover several affiliated companies.
Carriers filing this form
The 10 carrier groups with the most filings that include WC 00 01 04, out of 28 in total.
| Carrier | Filings | States | Editions, most filed first | Last filed |
|---|---|---|---|---|
| Brookfield Wealth Solutions Group4 group companies filed it, led by Argonaut Insurance Company and Argonaut-Midwest Insurance Company | 19 | 1 | A | Jun 4, 2026 |
| Nationwide Corporation Group3 group companies filed it, led by Crestbrook Insurance Company and National Casualty Company | 10 | 1 | A | Jun 30, 2026 |
| AXA Insurance Group5 group companies filed it, led by Greenwich Insurance Company and XL Insurance America, Inc. | 6 | 2 | A | Jun 23, 2026 |
| Tokio Marine Holdings Incorporated Group2 group companies filed it, led by Safety First Insurance Company and Safety National Casualty Corporation | 6 | 2 | A | May 14, 2025 |
| Intact Financial Group3 group companies filed it, led by Atlantic Specialty Insurance Company and OBI America Insurance Company | 5 | 1 | A | Jun 24, 2026 |
| OLD Republic Group2 group companies filed it, led by Great West Casualty Company and Old Republic Insurance Company | 5 | 5 | A | Apr 30, 2025 |
| RLI Insurance GroupRLI Insurance Company | 5 | 1 | A | Aug 18, 2026 |
| Sompo Group2 group companies filed it, led by Sompo America Fire and Marine Insurance Company and Sompo America Insurance Company | 5 | 1 | A | Jun 15, 2026 |
| State Farm GroupState Farm Fire and Casualty Company | 5 | 1 | A | May 4, 2026 |
| THE Hanover Insurance Group6 group companies filed it, led by Allmerica Financial Alliance Insurance Company and Allmerica Financial Benefit Insurance Company | 5 | 1 | A | Jun 23, 2026 |
How the largest insurers handle WC 00 01 04
Groups among the largest workers compensation insurers that filed WC 00 01 04 or their own version in the past five years.
- Amtrust Financial Services GroupUses WC 00 01 04 in 1 filing
States
Number of filings that include WC 00 01 04 in each state, Nov 2021 to Nov 2026. Darker states have more filings.
Often filed with
Standard-style form numbers that appear in the same filings most often.
- WC 00 01 06Longshoremen's and Harbor Workers' Compensation Act Coverage Endorsement109 filings
- WC 00 01 08Nonappropriated Fund Instrumentalities Act Coverage Endorsement109 filings
- WC 00 01 01Defense Base Act Coverage Endorsement106 filings
- WC 00 03 05Joint Venture as Insured Endorsement102 filings
- WC 00 03 13Waiver of Our Right to Recover From Others Endorsement102 filings
- WC 00 03 04Insurance Company as Insured Endorsement101 filings
- WC 00 03 08Partners, Officers and Others Exclusion Endorsement101 filings
- WC 00 03 11Voluntary Compensation and Employers Liability Coverage Endorsement101 filings
- WC 00 04 06Premium Discount Endorsement101 filings
- WC 00 01 09Outer Continental Shelf Lands Act Coverage Endorsement100 filings
Recent filings
Latest filings that include this form number. Filed copies open in FilingFocus.
| Submitted | Company | State | Editions | Tracking number |
|---|---|---|---|---|
| Nov 2, 2026 | AmFed Advantage Insurance Companyand 3 more | WA | A | GREY-135137891 |
| Oct 2, 2026 | AmFed Advantage Insurance Companyand 3 more | CA | A | GREY-135104146 |
| Sep 25, 2026 | AmFed Advantage Insurance Companyand 3 more | MI | Original | GREY-135103500 |
| Sep 16, 2026 | ZNAT Insurance Company | CT | A | ZICO-135090521 |
| Aug 18, 2026 | RLI Insurance Company | CO | A | RLSC-135057018 |
| Jun 30, 2026 | American Casualty Company of Reading, Pennsylvaniaand 5 more | CO | A | CNAB-135003197 |
| Jun 30, 2026 | Crestbrook Insurance Companyand 1 more | CO | A | NWPP-135003409 |
| Jun 30, 2026 | National Casualty Company | CO | A | NWPP-135004216 |
| Jun 24, 2026 | Atlantic Specialty Insurance Companyand 2 more | CO | A | BEAC-134978198 |
| Jun 23, 2026 | Allmerica Financial Alliance Insurance Companyand 5 more | CO | A | HNVX-134968029 |
| Jun 23, 2026 | AXA XL Insurance Company Americasand 3 more | CO | A | XLAM-134996276 |
| Jun 15, 2026 | Sompo America Fire and Marine Insurance Companyand 1 more | CO | A | SMPJ-134970923 |
Most filed NCCI WC forms
- WC 00 00 01 Information Page
- WC 00 04 19 Part Five, Premium Amendatory Endorsement
- WC 00 00 00 Workers Compensation and Employers Liability Insurance Policy
- WC 00 04 21 Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement
- WC 00 04 06 Premium Discount Endorsement
- WC 00 03 13 Waiver of Our Right to Recover From Others Endorsement
- WC 00 04 22 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement
- WC 00 03 08 Partners, Officers and Others Exclusion Endorsement
- WC 00 03 03 Employers Liability Coverage Endorsement
- WC 00 03 11 Voluntary Compensation and Employers Liability Coverage Endorsement
- WC 00 04 03 Experience Rating Modification Factor Endorsement
- WC 00 04 04 Pending Rate Change Endorsement