Submission Requirements

Submission Requirements:


To receive a premium quotation please provide the following:

  • ACORD application
  • 5 years currently valued loss runs, Ex-Mod history & final premiums (if available)
  • Description of operations including current safety/loss control procedures

To Complete the Membership Process:

Once the new member decides to move forward with the premium quotation, member information
is submitted to the MN Department of Commerce for final approval.

The following information is required by the Department of Commerce at this time:

  • $400 one time payment to:  MN Dept of Commerce
  • Experience modification worksheet from MWCIA or NCCI
  • Most current WC policy declaration pages
  • Five years of most recent review level financial statements prepared by an independent CPA required
    for final approval, with annual statements provided each year member participates in the fund
  • Signed application & indemnity agreements (we will provide these to review & sign)
  • The approval process with the MN Department of Commerce can take up to 60 days
  • A three-year commitment for new members joining the fund is required to avoid penalties, this helps
    protect the current members and provides a stable market for new members that join


– Please send all Submission Requirements to: