All states are eligible for other states coverage, except for California, Kentucky and New York (and of course, Texas). Also, the so-called "monopolistic states" of North Dakota, Ohio, Washington, West Virginia and Wyoming are excluded from other states coverage. The monopolistic states are also ineligible for other states endorsements.

• Florida has a special ACORD^® application. The application has specific information that must be acknowledged and signed by the agent and owner/officer, and the signatures must be notarized. We will offer our quote using a standard application, but we will require the Florida application be completed within 30 days of the policy effective date. Contact your underwriter for a copy of the Florida application.

Texas Mutual is replacing its Other States Endorsement. Effective July 1, 2008, we will automatically apply the coverage provided in the new Limited Reimbursement for Texas Employees Injured in Other Jurisdictions Endorsement (TM-LRC-2008) to all policies at no additional charge. Actual endorsements will be attached upon issuance of a new or renewal policy. You do not need to complete a supplemental application.

If your Texas-based client sends Texas employees temporarily to other states, this endorsement provides reimbursement for expenses incurred to meet other states' workers’ compensation laws (subject to the terms and conditions of the endorsement).

An applicant for our other states program must be Texas-based policyholder to be eligible. Up to 35 percent of the policyholder's total governing class payroll can be in states outside Texas, regardless of the number of other states in which coverage is needed.

To find the maximum for each individual state, if the applicant needs coverage in only one state outside Texas, see this chart

New Business information required:

• Completed, readable ACORD^® application for all policies
• Type of entity (corporation, sole proprietor, etc.)
• FEIN for each entity, including DBA names
• Physical location addresses, incl. ZIP codes, listed by entity (not P.O. Box)
• SIC code or description of operations
• Annual payroll by class code by state
• Premium and loss history for last four years separate from Texas
• Expected effective date:________
• Coverage B limits of liability
• Date of birth, title and job duties for executive officers, partners or sole proprietors
• Current experience mod worksheet
  
  If applicable:
  • Verification of special coverages (i.e. USL&H, Maritime, Waiver of Sub., OCS)
  • State unemployment Tax ID # for:_____ (CO, MA, ME, NM, MY, IN, MN, ID)
  • New Jersey Employer Registration #:_____

Renewal information required:

• Current experience modification worksheet, if applicable
• Changes in operation, updated payrolls, classifications, any new states and addresses

Endorsement information required:

• Verification of effective date, location address, annual payroll, FEIN for any new entity
• ERM-14 for ownership change or name change

Cancellation Information Required:

• Lost Policy Receipt signed and witnessed on flat cancellations. Mid-term cancellations require insured’s signed request