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Assignment Additional Notice <br /> Notice <br /> COVERAGE FOR THIS EMPLOYER HAS BEEN PLACED THROUGH THE FLORIDA WORKERS ' COMPENSATION <br /> .. , . JOINT UNDERWRITING ASSOCIATION , INC . ( FWCJUA) . AS THE FWCJUA IS THE MARKET OF LAST <br /> RESORT, COVERAGE SHOULD CONTINUE TO BESOUGHT THROUGH THE STANDARD/VOLUNTARY <br /> MARKET. PLEASE NOTE THAT PREMIUMS IN THE FWCJUA MAY BE HIGHER THAN THE <br /> STANDARD/VOLUNTARY MARKET AND THIS EMPLOYER MAY BE SUBJECT TO FUTURE ASSESSMENTS . <br /> IF AN OFFER OF COVERAGE IS OBTAINED FROM A VOLUNTARY MARKET INSURER GROUP <br /> SELF-INSURERS ' FUND, COMMERCIAL SELF-INSURANCE FUND, OR AN ASSESSABLE MUTUAL INSURER, <br /> THIS EMPLOYER IS NO LONGER ELIGIBLE FOR COVERAGE THROUGH THE FWCJUA . ACCEPTANCE OF <br /> COVERAGE THROUGH THE FWCJUA BY AN EMLOYER CREATES A CONCLUSIVE PRESUMPTION THAT THE <br /> EMPLOYER IS AWARE OF THIS POTENTIAL. <br /> EMPLOYER : SINCE YOU HAVE BEEN UNABLE TO SECURE WORKERS ' COMPENSATION INSURANCE <br /> THROUGH ANY OTHER INSURANCE PROVIDER, YOUR COVERAGE IS BEING OFFERED THROUGH THE <br /> FLORIDA WORKERS ' COMPENSATION JOINT UNDERWRITING ASSOCIATION ( FWCJUA) AND YOUR <br /> PREMIUM IS SURCHARGED . <br /> If a policy issued, pursuant to an assignment under the FWCJUA, is cancelled due to the employer's <br /> failure to comply with terms or conditions of the policy, such employer may be ineligible for further <br /> coverage under the FWCJUA. <br /> 1 Service Provider: Form UCT-6 or its equivalent is attached . <br /> 2 Service Provider: A list of all employees for this employer is attached. <br /> 3 Service Provider: Experience Rating Worksheet is attached . <br /> 4 ERM- 14 is attached <br /> 5 Service Provider: Applicant 's Affidavit is attached . <br /> 6 Service Provider: Employment and Wage Information Release Agreement attached. <br /> 7 Employer: Since you have been unable to secure workers' compensation insurance through any <br /> other insurance provider, your coverage is being afforded by the Florida Workers Compensation <br /> Joint Underwriting Association. ( FWC3UA) and your premium is surcharged . <br /> 8 The FWCJUA does provide limited coverage for exposures in other states that are incidental with <br /> respect to Florida employers and employees, but the FWCJUA will not provide coverage for any <br /> known or anticipated workers' compensation exposures in states other than Florida . <br /> .9 You have been assigned to Tier III, which is an assessable plan and is subject to a 170% <br /> surcharge on the annual premium . Employers qualifying for Tier III shall be required to <br /> contribute on a pro- rata-earned-premium basis the money necessary to meet any assessment <br /> levied to cover any deficit attributable to Tier III. <br /> 10 All Parties : For purposes of coverage with the FWCJUA, any employer enrolled in an employee <br /> leasing arrangement will be deemed the Employer for both its leased and non-leased workers. <br /> Therefore, a client/ employer entered into a leasing arrangement to fulfill its statutory <br /> obligations to its workers through the FWCJUA shall be responsible to pay premiums to the <br /> FWCJUA that includes remuneration paid to both leased and non -leased workers . <br /> AA Increased Limits : (in thousands) 500 / 500/ 500 <br /> zai 7Ce1 a i 72570 <br /> 2 <br />