Coverage description
A National Council on Compensation Insurance (NCCI) standard form. It replaces two premium sections of the policy: premium comes from manuals filed by the rating organization, a state bureau or the insurer and approved for use, and audit and retrospective premiums are due on the date the billing specifies.
Updated
What the form says
Key clauses from edition A, the latest revision, quoted as filed.
“filed by the state-designated workers compensation rating or advisory organization on our behalf”
WC 00 04 19 A · New in this edition
Whose manuals set the premium. Manuals filed for the insurer by the state's rating or advisory organization, by a state rating bureau, or by the insurer itself can all set the premium.
“the manuals also must be approved for use by the appropriate state insurance regulatory authority”
WC 00 04 19 A · New in this edition
Manuals must be approved. A filed manual applies only once the state regulator approves it for use, or where the law otherwise allows it.
“We may change our manuals and apply the changes to this policy and any renewals”
WC 00 04 19 A · New in this edition
When manual changes apply. Approved manual changes can be applied to the current policy and to its renewals.
“The due date for audit and retrospective premiums is the due date specified in the billing for the policy”
WC 00 04 19 A · New in this edition
When audit premium is due. Premium owed after an audit or under a retrospective rating plan is due on the date the bill names, not on the date the bill is issued.
How the form has changed
2 changes 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 editionAudit and retrospective premiums are due on the due date stated in the billing, instead of on the date of the billing.
Original edition
“The due date for audit and retrospective premiums is the date of the billing.”
Edition A
“is the due date specified in the billing for the policy”
Adds a replacement Our Manuals section: premium comes from manuals filed by the rating organization, a state rating bureau or the insurer and approved for use, and approved changes can apply to renewals.
Original edition
Not in this edition
Edition A
“Developed in any format and filed by us with the appropriate state insurance regulatory authority”
Revision A also retitles the form from Premium Due Date Endorsement to Part Five Premium Amendatory Endorsement.
Editions
Revision letters as filed, newest first. Filing counts include every state submission that lists the edition.
| Edition | Filings | Companies | States | Filed | Document |
|---|---|---|---|---|---|
| ALatest | 339 | 118 | 39 | Dec 2021 to Aug 2026 | View PDF |
| Original | 94 | 69 | 26 | Jan 2022 to Sep 2026 | View PDF |
1 other edition date appears in one or two filings each, often carrier-specific versions: F.
Where filings record what this form replaced, they name earlier edition 09 14 and other forms WC 00 04 14. Only some filings record replacements.
What the filings show
- Edition in use: in the past 12 months, 46 companies filed edition A and 20 companies filed the original edition.
- WC 00 04 21 (Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement) is filed alongside it most often, in 177 of the same filings (44%).
Filed under
Data from admitted P&C filings with state insurance departments, submitted Nov 2021 to Sep 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 04 19, out of 51 in total.
| Carrier | Filings | States | Editions, most filed first | Last filed |
|---|---|---|---|---|
| WR Berkley Corporation Group14 group companies filed it, led by Intrepid Insurance Company and Berkley National Insurance Company | 130 | 34 | A | Jun 17, 2026 |
| American Financial Group8 group companies filed it, led by Great American Spirit Insurance Company and Great American Alliance Insurance Company | 37 | 32 | AOriginal | Jun 19, 2024 |
| National Council on Compensation Insurance, Inc.Advisory Organization | 31 | 29 | AOriginal | May 16, 2023 |
| Acuity, A Mutual Insurance Company | 24 | 18 | AOriginal | Jul 1, 2026 |
| Brookfield Wealth Solutions Group5 group companies filed it, led by Argonaut Insurance Company and Argonaut-Midwest Insurance Company | 20 | 1 | AOriginal | Jun 25, 2026 |
| Nationwide Corporation Group9 group companies filed it, led by AMCO Insurance Company and Crestbrook Insurance Company | 20 | 1 | AOriginalF | Jun 30, 2026 |
| Mutual Capital Group Incorporated GroupIllinois Casualty Company | 16 | 11 | AOriginal | Oct 30, 2025 |
| United Fire & CAS GroupUnited Fire and Casualty Company | 13 | 11 | AOriginal | May 4, 2026 |
| OLD Republic Group3 group companies filed it, led by Great West Casualty Company and Old Republic Insurance Company | 7 | 6 | OriginalA | Apr 30, 2025 |
| Tokio Marine Holdings Incorporated Group2 group companies filed it, led by Safety First Insurance Company and Safety National Casualty Corporation | 7 | 3 | AOriginal | May 14, 2025 |
How the largest insurers handle WC 00 04 19
Groups among the largest workers compensation insurers that filed WC 00 04 19 or their own version in the past five years.
- Amtrust Financial Services GroupUses WC 00 04 19 in 1 filing
- Chubb Limited GroupUses WC 00 04 19 in 1 filing
States
Number of filings that include WC 00 04 19 in each state, Nov 2021 to Sep 2026. Darker states have more filings.
Often filed with
Standard-style form numbers that appear in the same filings most often.
- WC 00 04 21Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement177 filings
- WC 00 04 06Premium Discount Endorsement174 filings
- WC 00 04 22Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement158 filings
- WC 00 04 14Notification of Change in Ownership Endorsement152 filings
- WC 00 00 00Workers Compensation and Employers Liability Insurance Policy151 filings
- WC 00 03 08Partners, Officers and Others Exclusion Endorsement148 filings
- WC 00 03 10Sole Proprietors, Partners, Officers and Others Coverage Endorsement147 filings
- WC 00 04 03Experience Rating Modification Factor Endorsement147 filings
- WC 00 03 13Waiver of Our Right to Recover From Others Endorsement146 filings
- WC 00 03 01Alternate Employer Endorsement144 filings
Recent filings
Latest filings that include this form number. Filed copies open in FilingFocus.
| Submitted | Company | State | Editions | Tracking number |
|---|---|---|---|---|
| Sep 16, 2026 | ZNAT Insurance Company | CT | Original | ZICO-135090521 |
| Aug 18, 2026 | RLI Insurance Company | CO | A | RLSC-135057018 |
| Aug 7, 2026 | Motorists Commercial Mutual Insurance Company | WY | Original | BSIN-135025946 |
| Jul 1, 2026 | Acuity, A Mutual Insurance Company | CO | A | ACUT-134982793 |
| 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 | AOriginal | NWPP-135004216 |
| Jun 25, 2026 | American National Property And Casualty Company | CO | A | ANPC-134996042 |
| Jun 24, 2026 | Atlantic Specialty Insurance Companyand 2 more | CO | A | BEAC-134978198 |
| Jun 23, 2026 | Allmerica Financial Alliance Insurance Companyand 5 more | CO | Original | HNVX-134968029 |
| Jun 23, 2026 | AXA XL Insurance Company Americasand 3 more | CO | Original | XLAM-134996276 |
| Jun 17, 2026 | Berkley National Insurance Companyand 5 more | CO | A | BNIC-134990058 |
Most filed NCCI WC forms
- WC 00 00 01 Information Page
- 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
- WC 00 03 01 Alternate Employer Endorsement