Section II - Reporting Requirements

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A. Rules Common to Premiums and Losses

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  1. Form of Report
    Reports consist of experience cards comprising an exhibit of exposures, premium and losses, together with Individual Case Reports as required in Section III of this Plan. The required forms for reporting the data may be ordered from the National Council on Compensation Insurance. All submissions MUST be typed or clearly printed. A sample of each form is in Section VIII. A list and description of the various forms follows.Unit report data may be submitted electronically in lieu of the above hard copy reports. For further information regarding electronic reporting, please contact the DCRB.

    Form Number Description
    NC2957 First Reporting
    NC2913 Supplemental Loss Reporting
    NC2957 Revised Exposures and Premiums
    NC2913 Revised Loss Reporting
    NC1047 Individual Case Report
    NC2400 Letter of Transmittal — Hard Copy
    NC302 Summary Report – Three-Year Fixed Rate Policies
  2. Estimated Audits
    If for any reason data is unavailable to the carrier before the filing date, an estimated audit must be filed with the DCRB and the Policy Conditions field “Estimated Audit Code” shall be marked with the appropriate code.
  3. Fraction of Dollars
    Fraction of Dollars. Report all monetary amounts in whole dollars only.
  4. Method of Transmittal
    1. Experience reports shall be submitted on a monthly basis, except that the carrier may submit reports more frequently if the carrier so desires.
    2. Experience reports shall be transmitted to the DCRB with a standard letter of transmittal, Form NC2400, signed by a responsible official of the carrier. The transmittal form may show the summary totals. The use of a stamped signature is permissible.
  5. Dates
    All dates shall be reported using a numeric designation, e.g. April 1, 1996 should appear as 04-01-96
  6. Policy Information
    1. Report Number. In the space provided in the upper left-hand corner of Form NC2957 or NC2913 report the 2-digit numeric code that corresponds to the loss valuation date.
      1. First Reports are valued as of the 18th month after the month in which the policy became effective, and the report shall be filed not later than 20 months after the effective date of the policy.
      2. Subsequent Reports
        1. Second reports are valued exactly 30 months from the policy effective date.
          Third reports are valued exactly 42 months from the policy effective date.
          Fourth reports are valued exactly 54 months from the policy effective date.
          Fifth reports are valued exactly 66 months from the policy effective date.
          Sixth reports are valued exactly 78 months from the policy effective date. Seventh reports are valued exactly 90 months from the policy effective date.
          Eighth reports are valued exactly 102 months from the policy effective date.
          Ninth reports are valued exactly 114 months from the policy effective date.
          Tenth reports are valued exactly 126 months from the policy effective date.
    2. Correction Report Number. Report the 2-digit sequential number that corresponds to the number of correction reports submitted within a particular report level. Refer to Section 1, Item L.8. for conditions requiring a correction report.
      Example: 3rd correction to a first report = Report Number “01”, Correction Number “03” Report blanks for original report level submissions on hard copy.
    3. Correction Type. Report the 1-position alphabetic code that indicates the type of correction report being submitted. Applicable only to correction reports.
      1. H – Header Record Correction
      2. E – Exposure Record Correction (First Reports Only)
      3. L – Loss Record Corrections
      4. T – Total Record Correction
      5. M – Correction to Multiple Record Types
    4. Carrier Code. The carrier code shall be inserted in the space provided. Refer to the National Council on Compensation Insurance, Inc. for the appropriate 5-digit code number.
    5. Policy Number. The complete policy number must be shown on the unit report AND MUST AGREE WITH THE POLICY NUMBER SHOWN ON THE POLICY INFORMATION PAGE. The complete policy number including prefixes and suffixes, if used, must remain the same throughout the life of the policy. In those cases where a policy is renewed by a renewal certificate, the policy number must be shown. If the carrier desires, the certificate number may also be shown under the field Certificate Number.
    6. Policy Effective Date. The effective date should correspond exactly with that shown on the policy information page or endorsements attached thereto. In the case of an interstate policy endorsed after its effective date to provide coverage for Delaware, the effective date shown on the risk report for Delaware shall be the effective date of the interstate policy. The effective date of the coverage for Delaware shall be indicated in the space captioned State Effective Date.
    7. Policy Expiration Date. The expiration date shall be the expiration date shown on the policy information page unless the policy is canceled. In that event, the cancellation date shall be recorded as the expiration date.
    8. Exposure State. Report the 2-digit numeric code that represents the state in which coverage has been provided
      • Delaware – 07
    9. State Effective Date. The date coverage begins in Delaware on a multistate policy where Delaware is added mid-term. Otherwise leave blank.
    10. Risk ID Number. The Risk ID Number is not required by the DCRB.
    11. Page Number. The Page Number is not required by the DCRB.
    12. Insured Name. Report the name of the person or business with whom an insurance contract is made and who is specifically designated by name in Item 1 of the policy information page or as endorsed.
    13. Insured Address. The Insured Address is not required by the DCRB.
    14. Federal Employer ID Number. Report the Federal Employer Identification Number as shown on the policy information page.
    15. Modification Effective Date. The Modification Effective Date is required for all exposures. If the modification changes in accordance with Experience Rating Plan rules, report the effective date of the modification that applies to the class code, rate, exposure, and premium.
    16. Rate Effective Date. Rate Effective Date is required for all exposures. Report the rate effective date that corresponds to the class code and its associated rate, exposure and premium. If the rating value changes during the policy period, report the rate effective date that applies to the reported class code, rate, exposure and premium.
  7. Policy Conditions
    Report the 1-position indicator or code for each policy condition that applies: three-year fixed rate indicator, multistate policy indicator, estimated audit code, retrospective rated indicator, canceled mid-term indicator and managed care organization indicator.
  8. Policy Type ID Code
    Identifies the type of coverage, plan indicator and non-standard provisions of the policy.
    Type of Coverage

    Code Description
    01 Standard Workers Compensation Policy
    05 Large Risk Rated Option / Large Risk Alternative Rating Option
    09 Non-Standard Policy

    Plan Type

    Code Description
    01 Voluntary Policy
    02 Normal Assigned Risk Policy

    Non-Standard Type

    Code Description
    01 Non-Standard Code Does Not Apply
    08 Exclusion of Executive Officers
    09 Voluntary Coverage Not Mandatory by State Act
  9. Deductible Type Codes
    Report the two 2-digit codes that identify the type of deductible being reported.
    Losses Subject to Deductible Code

    Code Description
    00 No Deductible
    01 Medical Losses Only
    02 Indemnity Losses Only
    03 Medical & Indemnity Losses

    Basis of Deductible Calculation Code

    CodeDescription
    00No Deductible
    01Per Claim
    02Per Accident
    03Per Policy Aggregate Limit
    04 Percent of Claim Cost
    05 Percent of Premium
    06 Coinsurance Only Percent with Per Claim Limit
    07Coinsurance Percent with Per Claim Amount and Coinsurance Limit
    08Coinsurance Percent with Per Accident Amount and Coinsurance Limit
    09Per Accident Amount with Per Policy Aggregate Limit
    10Per Claim Amount with Per Policy Aggregate Limit
    11Coinsurance Percent With Per Claim Amount Limit and Per Policy Aggregate Limit
    12Variable
  10. Deductible Percent
    Report the whole percent of the deductible to be paid by the insured, if applicable, as defined by the deductible program. Applicable only with deductible types 0104, 0105, 0204, 0205, 0304 and 0305.
  11. Deductible Amount Per Claim/Accident
    Report the loss amount by claim/accident to be paid by the insured, if applicable, as defined by the deductible program.
  12. Deductible Amount Aggregate
    Report the maximum loss amount for all claims to be paid by the insured, if applicable, as defined by the deductible program.

B. Exposure Information

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  1. Update Type
    Report the 1-position alphabetic code that identifies the activity of an exposure record.

    Code Description
    P Previously Reported
    R Revised
  2. Exposure Coverage
    Report the code indicating the Act (Law) under which the exposure for this record’s class code is associated.

    Code Description
    01 State Act or Federal Act, Excluding USL&HW and Federal Mine Safety and Health Act
    02 USL&HW “F” or USL&HW Coverage on non “F” Classes
    03 Federal Mine Safety and Health Act Only
    04 Federal Mine Safety and Health Act and the State Act
    10 Voluntary Coverage Not Mandatory by State Act
  3. Class Code
    Report the code corresponding to the insured’s classification determined according to classification rules of the DCRB and published in the Delaware Manual of Rules, Classifications and Rating Values for Workers Compensation and for Employers Liability Insurance.
  4. Exposure Amount
    The lines referenced in the following paragraphs, Items 4 through 10, pertain to the hard copy Unit Statistical Report.

    1. No Exposure in the State – When a policy is issued, either on an “if any” basis or as a multi-state policy, and upon audit it is determined that exposure did not develop, a first level unit report must be submitted containing either 1) no exposure records at all or 2) a single exposure record containing Class Code 1111, No Exposure. If the Class Code 1111 option is chosen, the class must be reported above Line “A” with no corresponding exposure, rate or premium amounts. All no exposure unit totals (exposure, premium, loss, etc.) must be equal to zero, and there should be no corresponding exposure or loss records reported. The use of either Option 1) or 2) above will alert the DCRB that no exposure developed in the state.
    2. Payrolls reported must be audited payrolls even on minimum premium risks. When a final audit has not been made at the time of filing a report, the policy condition field Estimated Audit Code should be marked with the symbol “Y”and without further request MUST be replaced by a revised report as soon as audited payrolls are available.
    3. Payrolls must be appropriately separated as of the effective date of the changes whenever there is a change in experience modification.
    4. The total payroll for all classifications is to be shown in the appropriate space provided on the line captioned Total Standard Exposures. In cases where more than one unit card is required for filing the experience under a given policy, it is important that the risk totals be shown on the last unit card.
    5. The payroll exposures for non-ratable (supplemental and catastrophe loadings) portions are not to be included in the Total Standard Exposure.
    6. The Manual rules provide that the payroll of all employees exposed to a foundry, abrasive, sand blasting hazard, carcinogen, radiation or federal black lung (except those rated under a classification where the DCRB Rating Values provide coverage for silicosis) will have a special supplementary disease rate charge in addition to the DCRB Loss Cost. Such payroll, together with the manual premium derived from the supplemental rate charge, shall be assigned to the appropriate code, such as 9985, 0175, or 0164. Refer to Section IV Item B.3. of this Plan for a complete list. The payroll reported for these codes shall be shown but shall not be used in determining the risk’s total payroll. However, the premium resulting from the application of the supplemental disease rates shall be included in the total premium reported.
    7. The Manual rules provide that the payroll of all employees exposed to or engaged in the following hazards will have a mandatory catastrophe reserve rate which is not subject to experience or retrospective rating in addition to the DCRB Loss Cost. Such payroll, together with the Manual premium from the mandatory catastrophe reserve rate charge, shall be assigned to the appropriate code:
      Class Hazard Code
      4771 Manufacturing of Explosives or Ammunition 0771
      7405 All members of the flying crew of scheduled and supplemental air carriers 7445
      7413 All members of the flying crew of commuter air carriers 7453

      To provide coverage for Federal Black Lung on class Code 0615, Tunneling and Shaft Sinking, the additional non-ratable disease loading Code 0164 and rating value must be applied to the payroll.

  5. Exposure-Other Than Payroll
    For a number of classifications, the Manual provides a basis of exposure other than payroll. The following method of reporting shall be used in such instances:

    1. Per Capita Classifications. Experience on per capita classifications shall be reported on the regular experience card, showing in the Exposure Amount column the number of persons exposed. An employee covered under a per capita classification for a period of one year shall be reported as an exposure of 1.0. Similarly, if coverage is terminated before the expiration of a year, the exposure reported per person shall be that decimal part of a year, expressed to the nearest tenth, for which the coverage was in effect. For example, an employee covered for four months should be reported as an exposure of 0.3. Exposure shall be governed by the duration of the coverage and not by the number of days worked.Note: Premium for Code 9740, Terrorism, and Code 9741, Catastrophe (other than Certified Acts of Terrorism), does not apply to these classifications.
  6. Carrier Rating Values
    The carrier’s rating values as shown in the compensation policy shall be shown against the classifications and payrolls to which they are applicable.
  7. Premium
    1. Premium by Classification. The premium reported by Manual classification shall be that obtained by extension of the payroll or other exposure at the carrier’s rating values, and shall be posted in the column captioned Premium Amount. Where a classification includes a non-ratable element or supplemental loading, the ratable portion of the premium should be shown above line “C” and the non-ratable portion should be shown below line “C.”Note: The non-ratable element or supplemental loading is subject to deviation, if applicable.
    2. Miscellaneous Premium. The DCRB rules provide for additional premium charges for various special conditions or additional coverage, such as Excess Limits under Part II, etc. These additional premium charges shall be reported in the column captioned Premium Amount under appropriate Class Code. (See Item B.3. of this Section). The exposure items, if any, shall be entered in the column captioned Exposure Amount.For all risks, whether subject to experience rating or not, the following rules apply.
      1. Miscellaneous premium shall be reported on one of the lines designated “D,” “E” or “F” if it is required by the Manual rules to be determined after application of the experience modification.
      2. All items of miscellaneous premium which do not fall under Item 1 above shall be reported on any of the blank lines above the line designated A-Total Subject Premium. For further details on the reporting of Miscellaneous Premium, refer to Item B.9. of this Section.
    3. Premium Totals on Risks not Subject to Experience Modification. For a risk, which is not subject to experience modification, DISREGARD line A-Total Subject Premium, line B-Experience Modification and line C-Total Modified Premium. The sum of the premiums by classification shown above line A-Total Subject Premium and/or on lines “D,” “E” and “F” shall be shown on the line captioned Total Standard Exposure.
  8. Exposure Total Record
    1. Premium Totals on Risks Subject to Experience Modification.
      1. Line A-Total Subject Premium. The total of the premium above this line, as per subsection a. and b. above, shall be entered in the premium column on the line captioned A-Total Subject Premium.
      2. Line B-Experience Modification. The experience modification used to develop charged premium, expressed as a decimal (e.g., .950 for 5% credit, 1.000 for a “neutral” modification, or 1.050 for a 5% debit), shall be entered in the premium column on the line captioned B-Experience Modification. If a change in the experience modification occurs subsequent to inception date of the policy, the payrolls, carrier’s rating values and corresponding premium shall be split and reported on separate reports. The period covered by each report shall be shown by appropriate notation in the Mod Effective Date and/or Rate Effective Date fields.Note: A “neutral” modification (1.000) may not be used for a non-rated risk.
      3. Line C-Total Modified Premium. The product of the premium as shown on the line A-Total Subject Premium and the experience modification as shown on line B-Experience Modification shall be entered on line C-Total Modified Premium.
      4. Line G-Total Standard Exposure. Report the sum of all dollar value exposures to be included in standard exposure.
      5. Line G-Total Standard Premium. Report the sum of all premium dollars, both subject and not subject to modification, which are to be included in standard premium.
      6. In those cases where the experience is reported on a split basis due to a change in experience modification and in other cases where more than one unit report card is required for filing the experience under a given policy, the Total Standard Premium shall be shown on the last card of the series.
  9. Miscellaneous Statistical Codes
    1. Premium Subject to Experience Modification to be reported on any of the blank lines above the line designated A-Total Subject Premium on the Hard Copy Unit Statistical Report.
      1. Premium for Increased Limits under Part II Codes 9803, 9805, 9806, 9807, 9808, 9810, 9811, 9812, 9814, 9815, 9816 and 9837 to be reported in the aggregate in the Premium Amount column, assigned to the appropriate code. Refer to Section IV for limits.
        1. Note: Increased Limit factors applied to non-ratable classification exposures should be reported as not subject to the experience modification. The DCRB Manual rules provide that the premium for limits in excess of the standard limits shall be determined by applying the appropriate factors to the total premium, at the carrier’s rates, before any applicable experience modification. The codes to be used are listed in Section IV, Item B.3.
          These codes should not be used in connection with the reporting of excess premium developed for increased limits on voluntary compensation policies. For such cases, the DCRB Manual rules contemplate that the premium for coverage in excess of standard limits is provided by an appropriate increase in the carrier’s rate.In those cases where the additional premium resulting from the application of the appropriate limit factor to total premium is less than the corresponding minimum premium established by the carrier for such increased limits, the corresponding minimum premium shall be shown opposite the appropriate Code 9848.
      2. Additional Premium Resulting From Flat Increase on Outstanding Policies – Code 0998. For policies where the effect of a law amendment has been applied during the term of the policy as a flat increase on total premium for the unexpired portion, the additional aggregate premium resulting from the flat increase shall be reported on a carrier’s Manual rate basis and shall be assigned to Code 0998 and entered in the Premium Amount column. The Exposure Amount and Manual Rate columns shall be left blank.
      3. Premium Credit Resulting From Flat Decrease on Outstanding Policies – Code 0994. For policies where the effect of a law amendment has been applied during the term of the policy as a flat decrease on total premium for the unexpired portion, the premium credit resulting from the flat decrease shall be reported on a carrier’s Manual rate basis and shall be assigned to Code 0994 and entered in the Premium Amount column. The Exposure Amount and Manual Rate columns shall be left blank.
      4. Waiver of Subrogation Premium – Code 0930. For Policies where the carrier waives subrogation rights, the premium charge associated with such waiver of subrogation shall be assigned to Code 0930 and entered in the “Premium” column. The “Exposure” and “Rate” columns shall be left blank.
    2. Premium Not Subject to Experience Modification, to be reported on lines “D,” “E” or “F” on the hard copy Unit Statistical Report.
      1. Short Rate Penalty Premium – Code 0931
        Where policies are canceled prior to normal expiration, the cancellation date shall be entered in the block captioned Policy Expiration Date and the symbol “Y” entered in the Policy Condition Field Canceled Mid-Term. When a policy is canceled short rate, the payroll and Manual premium by classification shall be reported on the basis of the actual exposure. Any deviation applied to Manual premium and the experience modification, if any, shall then be applied to the Manual premium to determine the total modified premium. The additional premium resulting from application of the short rate cancellation table to such modified premium extended to full annual basis shall be assigned to Code 0931 and reported in the Premium Amount column. The Exposure Amount and Manual Rate columns shall be left blank. (For an example, see Section VI.)
      2. Delaware Construction Classification Premium Adjustment Program (DCCPAP) Credit –  Code 9046
        For carriers using an approved DCCPAP credit, the premium adjustment resulting from the application of the credit factor to the Manual Premium (after the application of the experience modification) shall be reported under Code 9046.
      3. Delaware Workplace Safety Program (DWSP) – Code 9880
         For carriers using an approved DWSP credit, report the premium adjustment resulting from the application of the credit factor to the Manual premium (after application of experience modification) shall be reported under Code 9880.
      4. Schedule Rating Plan Adjustments
        Schedule Rating Plan Adjustments must be applied as a percentage factor applicable to manual premium after application of experience/merit rating but prior to any other credit (i.e., Delaware Safety Committee credit, Delaware Construction Classification Premium Adjustment Program)
        Code 9887 Schedule Rating Credit – to be subtracted when calculating standard premium
        Code 9889 Schedule Rating Debit – to be added when calculating standard premium.NOTE: USE ONLY POSITIVE VALUES
      5. Deductibles- Code 9663
        When a deductible has been elected, the premium on the policy shall be reduced by the deductible credit factor in accordance with the deductible table Section 1 of the Delaware Manual of Rules, Classifications and Rating Values for Workers Compensation and for Employers Liability Insurance. Such credit amount shall be reported under Code 9663.
      6. Merit Rating Plan Adjustments – Applicable on lines “D,” “E” or “F” (on the paper copy of the unit statistical report) in lieu of experience modification. Code 9884 – Neutral Adjustment – no credit or debit.
        Code 9885 – 5% Credit Adjustment – to be subtracted when calculating standard premium.
        Code 9886 – 5% Debit Adjustment – to be added when calculating standard premium.
        Merit Rating Adjustments are applicable to manual premium before application of any schedule rating, Delaware Safety Committee Credit or Delaware Construction Classification Premium Adjustment Program.
    3. Premium Not Subject to Experience Rating, to be Reported on line “H”, “I” or “J” on the Hard Copy Unit Statistical Report.
      1. Premium Discount – Code 006_. If premium discount is applied, the total amount of the discount for the state should be shown in the premium column on line “H” and shall be assigned to Statistical Code 0063 for Schedule “Y” carriers or Code 0064 for Schedule “X” carriers. THIS AMOUNT MUST NOT BE INCLUDED IN THE TOTAL STANDARD PREMIUM AMOUNT ENTERED. Be sure to complete the Code number “006_” to indicate which discount has been applied.
      2. Expense Constant – Code 0900. On each policy where an expense constant has been charged, the amount so charged shall be assigned to Code 0900 for all industry groups. Do not include the expense constant in the Total Standard Premium.
      3. Flat Charge Waiver of Subrogation – Code 9115. For policies where a flat charge has be levied for a waiver of subrogation rights, the amount shall be assigned to Code 9115. Do not include the flat charge waiver of subrogation premium in the Total Standard Premium. (See Item B.9.a.(4) of this section.)
      4. Terrorism – Code 9740. Premium charge for Terrorism is reported on a hard copy unit subsequent to experience modification after the expense constant, if applicable. The premium charge for Code 9740 is calculated by dividing a risk’s total payroll by $100 and multiplying the result times the carrier’s rating value for Code 9740. Premium developed under Terrorism is not included in Total Standard Premium. Non-payroll exposures are not subject to premium charges for Terrorism.
      5. Catastrophe (other than Certified Acts of Terrorism) – Code 9741. Premium charge for Catastrophe (other than Certified Acts of Terrorism) is reported on a hard copy unit subsequent to experience modification after the expense constant, if applicable. The premium charge for Code 9741 is calculated by dividing a risk’s total payroll by $100 and multiplying the result times the carrier’s rating value for Code 9741. Premium developed under Catastrophe (other than Certified Acts of Terrorism) is not included in Total Standard Premium. Non-payroll exposures are not subject to premium charges for Catastrophe (other than Certified Acts of Terrorism).
    4. Assigned Risk Surcharge – Code 0277. Premium Not Subject to Experience Rating, to be reported on line “K” on the hard copy Unit Statistical Report.
    5. Audit Noncompliance Charge (ANC) – Code 9757 For policies where the carrier has chosen to apply an audit noncompliance charge because the employer would not allow the carrier to examine and audit its records. The premium for Code 9757 is a flat charge applied after the Employer Assessment (Code 0938).
      Note: When the Exposure on the 1st report includes Code 9757, report the Estimated Audit Code as “U” in the applicable Policy Conditions, Estimated Audit Code field.
      If subsequent to reporting Statistical Code 9757, and the final policy premium is determined in accordance with the Basic Manual rules, the statistical code and its accompanying charge must be removed. Additionally, the Estimated Audit Code must be changed to “N” and the exposure and premium must reflect the final audit.
  10. Correction Reports-Method of Reporting
    1. Conditions Requiring a Correction Report
      1. A correction report shall be filed whenever there is an error of any kind on a report previously filed, whether such error is discovered by the carrier or by the DCRB.
      2. If the error involves a change on a case, which in the previous reporting required an Individual Case Report, a revised or corrected Individual Case Report shall be submitted with the revised risk exposure.
      3. Correction reports as defined above should be forwarded to the DCRB as soon as possible after the changes are known.
    2. Method of Reporting
      1. Correction for any month of issue shall be filed on NC2957 or NC2913 during the period when original reportings for the same year are being filed. All corrections must be clearly marked as corrections by inserting the 2-digit correction code that corresponds to the number of corrections submitted within a particular report level. Also the 1-position alphabetic correction type that indicates the type of correction being submitted should be entered in the Correction Type field.
      2. Where the classification code or type of injury requires correction, the corrected report shall show all of the data previously reported for the classification in question, as well as all of the data (including those items which do not change) on a corrected basis. (For examples, refer to Section VI.)
    3. If revision of payrolls and premiums are required, Form NC2957 shall be used.
    4. Correction reports should be forwarded to the DCRB as soon as possible after the changes are known.
    5. All correction reports should, in the Correction Type field indicate the type of correction being submitted. For example, due to an audit where the previous report was an estimate, the correction type would be “E” exposure. (For a list of Correction Type see Section II Item A.6.c.)
    6. Where the exposure previously reported has been changed by reason of an audit, or by a re-audit or any other adjustment affecting classifications, exposure or premiums, a revised report, Form NC2957 shall be filed showing the amounts reported previously, as well as revised amounts for those classifications where there have been changes.
    7. The lines captioned A-Total Subject Premium, B-Experience Modification and C-Total Modified Premium, (if these lines have been used on the prior report), together with the Total Standard Exposure and Total Standard Premium, shall be shown as revised only.
    8. If the exposure does not change but the risk total standard premium previously reported is revised due solely to a change in the experience modification, it shall be necessary to submit a revised report showing only each item affected by the modification change on a previously reported and revised basis.
    9. Previous premium discounts and revised discounts also shall be reported in the space provided.

C. Loss Information

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  1. Update Type
    Report the 1-position alphabetic code that identifies the activity of a loss record.

    Code Description
    P Previously Reported
    R Revised
  2. Claim Number
    1. Report the alphanumeric code that uniquely identifies the claim excluding blanks, punctuation marks and special characters. The complete claim number, including suffixes and prefixes, if used, must remain the same throughout the life of the claim.
  3. Accident Date
    Enter the accident date by reporting the month, day and year on which the injury occurred is required. In cases involving disease, the claim shall be assigned to the policy in force at the time the carrier became aware of the claim.In the event the carrier no longer insures the risk, the claim shall be assigned to the last policy issued by the carrier. The selected and indicated date of accident shall fall within the policy period.
  4. Incurred Indemnity
    Report the whole dollar amount of incurred indemnity expenses as of the loss valuation. These losses consist of all paid and outstanding reserve benefits due to an employee’s lost wages or inability to work, including compensation paid to the deceased prior to death, burial expenses, claimant’s attorney fees, vocational rehabilitation benefits, payments to the state and employers liability losses and expenses.Note: Allocated Loss Adjustment Expenses for other than Employers Liability coverage must be excluded from indemnity losses.
  5. Incurred Medical
    Report the whole dollar amount of incurred medical expenses, as of the loss valuation date. These losses consist of all paid and outstanding reserve benefits.
  6. Class Code
    In this column, show the classification code number to which the claim has been assigned. Report the code corresponding to the insured’s classification determined according to the classification rules of the DCRB. No claims may be assigned to any classification unless premium also has been reported for that class. In cases where losses have been incurred under the benefits of a state other than where payroll is assigned, the carrier shall report the claim in the state where the payroll is assigned, identifying the claim in the Jurisdiction State field.
  7. Injury Type
    Report the 2-digit numeric code that identifies under which provision of the law benefits are paid or expected to be paid.

    1. Death Cases Code – 01
      1. Enter each death case, unless it has been established that the carrier has incurred no liability. The amount entered, as indemnity incurred shall include all paid and outstanding benefits, including compensation paid to the deceased prior to death, burial expenses, with a maximum of $3,000 and payments to the state.
        If there is compensation paid on a permanent total, permanent partial or a temporary claim prior to the death of a claimant and the death is not related to work injuries, the loss is to be reported on the basis of the injury for which payments have been previously made.
        In valuing a surviving spouse’s benefits in death cases, Table I, Surviving Spouse Pension Table, shall be used. (For example, see Section VI.) In valuing the portion of reserves in death cases for lump sum dowry benefits payable to the surviving spouse upon remarriage, Table II, Present Value of Remarriage Award Table, shall be used. In valuing the benefits for certain death claims where there is no surviving spouse, but a parent, brother or sister receiving benefits which are payable for life, Table III, Lifetime Benefits (Other Than Surviving Spouse) Pension Table, shall be used. (Refer to Section V for the Tables.)
      2. USL&HW Benefits on Death Cases. In valuing a surviving spouse’s benefits in death cases under USL&HW Coverage, Table USL&HW-I, Surviving Spouse Pension Table, shall be used. In valuing the portion of reserves in death cases under USL&HW Coverage for lump sum dowry benefits payable to the surviving spouse upon remarriage, Table USL&HW-II, Present Value of Remarriage Award Table shall be used. In valuing the portion of reserves certain death cases under USL&HW Coverage where there is no surviving spouse, but a parent, brother or sister receiving benefits which are payable for life, Table USL&HW-III, Lifetime Benefits (Other Than Surviving Spouse) Pension Table, shall be used.
    2. Permanent Total Disability Code – 02
      1. Enter as permanent total each case which has been adjudged to constitute permanent total disability or which is defined as such under the law, or which in the judgment of the carrier will result in permanent total disability. In general, permanent total disability includes cases involving the loss, or loss of use, of both hands, both arms, both feet, both legs, or both eyes. If a lump sum settlement is made or, in judgment of the carrier, will be received to settle future benefits, the injury code should be changed from a permanent total to a permanent partial. In establishing reserves on permanent total cases, Table III, Lifetime Benefits (Other Than Surviving Spouse) Pension Table, shall be used, as found in Section V. (For examples, see Section VI.)
      2. USL&HW Benefits on Permanent Total Cases. In valuing the disabled’s life portion of the reserve for permanent total cases under USL&HW Coverage, Table USL&HW-III, Lifetime Benefits (Other Than Surviving Spouse) Pension Table, shall be used. In valuing the portion of the reserve for permanent total cases in which survivorship benefits are payable, Table USL&HW-IV, Present Value of Survivorship Benefits Table, shall be used. (For an example, see Section VI.)
    3. Temporary Total or Temporary Partial Disability Code – 05 Enter as Temporary every case, which involves or is expected to involve indemnity benefits but which does not constitute a case of Death, Permanent Total or Permanent Partial as defined above.
    4. Medical Only Claims Code – 06 When reporting medical only losses, make no entry in the column captioned Incurred Indemnity.
    5. Contract Medical Code – 07 Contract medical costs, which cannot be allocated to individual claims, shall be reported in the aggregate in the column captioned Medical Incurred. Such medical shall be assigned to the governing classification of the risk. Contract medical costs allocated to individual claims shall be reported in connection with these claims and shall not be included in the amount reported as contract medical. The amount reported, as contract medical shall be the actual incurred cost to the company for such medical contracts, including payments to physicians and hospitals under contract.
    6. Permanent Partial Disability Code – 09
      1. Cases involving partial disability or permanent injuries, as defined in Sections 2325 or 2326, respectively, of the Workers’ Compensation Act. Such cases involve loss, or loss of use, of members of the body, sight or hearing and disfigurement of the head, neck or face. Do not include permanent injuries defined as Permanent Total above.
      2. Cases involving total disability, other than permanent total disability, if either of the following holds true:
        1. The duration of the disability benefits exceeds, or is expected to exceed, one year.
        2. In the judgment of the carrier, the extent of liability for future payments is indeterminate. The amount entered as indemnity incurred shall include specific benefits and compensation for temporary disability as well as loss of earning capacity. (For examples, see Section VI.)
  8. Claim Status
    Report the 1-digit numeric code that indicates the status of the claim.

    Code Description
    0 Open (final payment not made)
    1 Closed
  9. Loss Condition Codes
    Report the 2-digit code for each loss condition.Loss Coverage Act

    Code Description
    01 State Act or Federal Act Excluding USL&HW and Federal Mine Safety and Health Act
    02 USL&HW “F” or USL&HW Coverage on non “F” Classes
    03 Federal Mine Safety and Health Act Only
    04 Federal Mine Safety and Health Act and the State Act

    Type of Loss

    Code Description
    01 Trauma
    02 Occupational Disease (OD)
    03 Cumulative Injury other than Disease

    Type of Recovery

    Code Description
    01 No Recovery
    02 Second Injury Only
    03 Subrogation Only (Third Party)
    04 Subrogation with Second Injury

    Type of Claim

    Code Description
    01 Workers’ Compensation Only
    02 Employers’ Liability Only
    03 Workers’ Comp. & Employers’ Liability

    Type of Settlement

    Code Description
    00 Claim Not Subject to Settlement
    03 Stipulated Award (Carrier/Claimant Settlement)
    04 Findings and Award (Judicial Award)
    05 Dismissal (Non-Compensable)
    06 Compromise Settlement
    09 All Other Settlements
  10. Jurisdiction State
    Report the 2-digit state code of the governing jurisdiction which will administer the claim and which statutes will apply to the claim adjustment process when that state is different from the exposure state.
  11. Catastrophe Number (Cat. No.)
    Any accident resulting in two or more reported claims must be reported as a catastrophe. In reporting catastrophes, all claims (compensable as well as non-compensable and contract medical) resulting from this accident shall be designated by placing the numeral “1” in the column captioned Cat. No. opposite each claim. If there is more than one catastrophe under the policy, each succeeding catastrophe should be designated by means of a separate serial number “2”, “3”, etc., up to and including “10”. After the number “10” is assigned the next number in the sequence will reprocess to number “1”. Numbers “11” through “99” are reserved for ISO assigned catastrophe codes. A separate series of catastrophe numbers shall be used for each policy.EXCEPTIONS:

     

    1. Report Catastrophe Code Number 48 for all claims directly arising from the commercial airline hijackings of September 11, 2001 and the resulting subsequent events with accident dates of September 11, 2001 through September 14, 2001.
    2. Report Catastrophe Code Number 87 for all occupational diseases claims emanating from the rescue, recovery and clean-up operations at the World Trade Center site that were undertaken between September 11, 2001 and September 12, 2002, as defined in Article 8-A of the New York Workers’ Compensation Law (Chapter 446 of the Laws of 2006).
    3. Report Catastrophe Code Number 12 for claims applicable and/or attributable to Coronavirus Disease 2019 (COVID-19) with accident dates of December 1, 2019 and subsequent
      Note: Catastrophe Code Number 48 and 87 will apply to both single and multiple claims.
  12. Managed Care Organization Type
    Report the 2-digit code that corresponds to the type of organization which will administer the applicable medical losses.

    Code Description
    00 The claim is not administrated by an approved managed care organization (MCO).
    01 The claim’s medical losses are administrated by an approved managed care organization (MCO) not specifically listed in Codes 02-05 below.
    02 The claim’s medical losses are administrated by a health maintenance organization (HMO).
    03 The claim’s medical losses are administrated by a preferred provider organization (PPO).
    04 The claim’s medical losses are administrated by an exclusive provider organization (EPO).
    05 The claim’s medical losses are administrated by an independent practice association (IPA).
  13.  Injury Description Code
    Report the three 2-digit codes that represent the part of body, nature of injury and cause of injury for a given claim. (Refer to Section IV for list of codes.)
  14. Occupation Description
    Report a narrative description of the regular occupation of the claimant for claims with indemnity or medical value greater than $25,000.
  15. Vocational Rehabilitation Indicator
    Report the 1-position code that indicates the inclusion of vocational rehabilitation costs in the losses.

    Indicator Description
    Y Claim includes Vocational Rehabilitation Costs
    N Claim does not include Vocational Rehabilitation Costs
  16. Lump Sum Indicator
    Report the value that identifies a lump sum agreement for the claim.

    Indicator Description
    Y Claim has been settled by an agreement to a lump sum amount.
    N Claim has not been settled with a lump sum agreement.
  17. Fraudulent Claim Code
    Report the 2-position code that indicates the claim status as respects occurrence of fraud. Code to be determined based on entry or filing of an order or other formal finding by a court or other judicial authority having jurisdiction over the case.

    Code Description
    00 Not Fraudulent
    01 Partially Fraudulent
    02 Fully Fraudulent
  18. Paid Indemnity
    Report the whole dollar amount of paid indemnity expenses for the claim as of the loss valuation date. These losses consist of all paid benefits due to an employee’s lost wage or inability to work, including compensation paid to a deceased prior to death, burial expense, claimant’s attorney fees, vocational rehabilitation benefits, payments to the state and employers liability losses and expenses.
  19. Paid Medical
    Report the whole dollar amount of medical losses paid for the claim as of the loss valuation date.
  20. Claimant’s Attorney Fees Incurred (Optional)
    Report the whole dollar amount paid plus outstanding reserves for claimant’s legal representation during the settlement of the claim as of the loss valuation date.
  21. Employer’s Attorney Fees
    Report the whole dollar amount paid plus outstanding reserves for employer’s legal representation during the settlement of the claim as of the loss valuation date.
  22. Weekly Wage Amount
    Report the actual weekly wage amount at the date of injury upon which the indemnity benefits are based. (Do not report the maximum or minimum weekly earnings specified in the state law.)
  23. Allocated Loss Adjustment Paid (ALAE)
    Report the whole dollar amount of loss adjustment expense allocated and paid for this claim as of the loss valuation date.
  24. Allocated Loss Adjustment Incurred (ALAE) (Optional)
    Report the whole dollar amount of loss adjustment expense allocated and paid or reserved for this claim as of the loss valuation.

D. Loss Totals

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  1. Total Number of Claims
    Report the total number of claims reported for the state within the policy. In the case of corrections and subsequent reports, this must be the revised total.
  2. Total Incurred Indemnity
    Report the arithmetic total of the incurred indemnity amounts reported for the state within the policy. In the case of corrections and subsequent reports, this must be the revised total.
  3. Total Incurred Medical
    Report the arithmetic total of the incurred medical amounts reported for the state within the policy. In the case of corrections and subsequent reports, this must be the revised total.
  4. Total Paid Indemnity
    Report the arithmetic total of the paid indemnity amounts reported for the state within the policy. In the case of corrections and subsequent reports, this must be the revised total.
  5. Total Paid Medical
    Report the arithmetic total of the paid medical amounts reported for the state within the policy. In the case of corrections and subsequent reports, this must be the revised total.
  6. Total Claimant’s Attorney Fees (Optional)
    Report the arithmetic total of the incurred claimant’s attorney fees reported for the state within the policy. In the case of corrections and subsequent reports, this must be the revised total.
  7. Total Employer’s Attorney Fees
    Report the arithmetic total of the incurred employer’s attorney fees reported for the state within the policy. In the case of corrections and subsequent reports, this must be the revised total.
  8. Total ALAE Paid
    Report the arithmetic total of the paid ALAE amounts reported for the state within the policy. In the case of corrections and subsequent reports, this must be the revised total.
  9. Total ALAE Incurred (Optional)
    Report the arithmetic total of the incurred ALAE amounts reported for the state within the policy. In the case of corrections and subsequent reports, this must be the revised total.