STATE OF NEVADA. December 12, Industrial Insurance NCCI Revisions to Statistical Plan for Workers Compensation and Employers Liability Insurance

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1 BRIAN SANDOVAL Governor STATE OF NEVADA TERRY JOHNSON Director SCOTT J. KIPPER Commissioner DEPARTMENT OF BUSINESS AND INDUSTRY DIVISION OF INSURANCE 1818 East College Pkwy., Suite 103 Carson City, Nevada (775) Fax (775) Website: doi.nv.gov December 12, 2011 Lorne Malkiewich Director State of Nevada Legislative Counsel Bureau Legislative Building 401 S. Carson Street Carson City, NV Via Re: Industrial Insurance NCCI Revisions to Statistical Plan for Workers Compensation and Employers Liability Insurance Dear Director Malkiewich: Pursuant to NRS 686B.177, we are required to report any changes in rates or in the Uniform Plan for Rating Experience, the Uniform Statistical Plan or the Uniform System of Classification to you. Enclosed, please find a PDF copy of the entirety of the recently approved filing made by the National Council on Compensation Insurance, Inc. ( NCCI ), with NCCI tracking number U-1398 and Nevada State tracking number This filing contains a variety of rule revisions, within the following six categories: 1. Revision of Noncompensable and Fraudulent Claims Reporting 2. Revision of Permanent Partial Injury Type 3. Elimination of Hard-Copy Reporting 4. Elimination of Medical-Only Group Claim Reporting 5. Addition of Cause-of-Injury Code 6. Reporting Clarifications

2 These rule revisions will not result in an impact on insureds premiums or on NCCI s approach to experience rating. NCCI intends the rules to enhance the understanding of the rules in the Statistical Plan and provide further direction for reporting unit statistical data. These revisions will affect the manner in which insurers report data to NCCI. Furthermore, the extent of workers compensation coverage available to protect employees is prescribed by Nevada statutes and will not be affected by this filing. If you have any questions or desire additional information, please feel free to contact me via at Sincerely, Mr. Gennady Stolyarov II, CPCU, ARe, AIS, AIE Actuary I Property and Casualty Section Nevada Division of Insurance cc: Scott J. Kipper, Commissioner of Insurance Marie Holt, Chief Examiner, Property & Casualty Section

3 SERFF Tracking Number: NCCI State: Nevada Filing Company: NCCI State Tracking Number: Company Tracking Number: U-1398 (LW) TOI: 16.0 Workers Compensation Sub-TOI: Standard WC Product Name: U-1398 Revisions to Statistical Plan for Workers Compensation and Employers Liability Insurance Project Name/Number: / Filing at a Glance Company: NCCI Product Name: U-1398 Revisions to Statistical SERFF Tr Num: NCCI State: Nevada Plan for Workers Compensation and Employers Liability Insurance TOI: 16.0 Workers Compensation SERFF Status: Closed-Approved State Tr Num: Sub-TOI: Standard WC Co Tr Num: U-1398 (LW) State Status: Approved Filing Type: Rule Reviewer(s): Mr. Gennady Stolyarov II Authors: Lesley O'Brien, Alison Disposition Date: 12/12/2011 Herwig, Frank Gnolfo, Maggie Karpuk, karin Steger, Robert Dalton Date Submitted: 10/27/2011 Disposition Status: Approved Effective Date Requested (New): 01/01/2013 Effective Date (New): Effective Date Requested (Renewal): 01/01/2013 Effective Date (Renewal): State Filing Description: General Information Project Name: Status of Filing in Domicile: Project Number: Domicile Status Comments: Reference Organization: Reference Number: Reference Title: Advisory Org. Circular: Filing Status Changed: 12/12/2011 State Status Changed: 12/12/2011 Deemer Date: Created By: Frank Gnolfo Submitted By: Frank Gnolfo Corresponding Filing Tracking Number: State TOI: 16.0 Workers Compensation State Sub-TOI: Standard WC Filing Description: The purpose of this item is to clarify and enhance the rules of NCCI s Statistical Plan for Workers Compensation and Employers Liability Insurance (Statistical Plan). In addition, this item includes clarification in NCCI s Experience Rating Plan Manual for Workers Compensation and Employers Liability Insurance (Experience Rating Plan) to support these changes. Company and Contact PDF Pipeline for SERFF Tracking Number NCCI Generated 12/12/ :15 AM

4 SERFF Tracking Number: NCCI State: Nevada Filing Company: NCCI State Tracking Number: Company Tracking Number: U-1398 (LW) TOI: 16.0 Workers Compensation Sub-TOI: Standard WC Product Name: U-1398 Revisions to Statistical Plan for Workers Compensation and Employers Liability Insurance Project Name/Number: / Filing Contact Information Maggie Karpuk, State Relations Executive Agoura Road, Suite [Phone] Agoura Hills, CA [FAX] Filing Company Information NCCI CoCode: State of Domicile: Florida 901 Peninsula Corporate Circle Group Code: Company Type: Boca Raton, FL Group Name: State ID Number: (561) ext. [Phone] FEIN Number: Filing Fees Fee Required? Yes Fee Amount: $25.00 Retaliatory? No Fee Explanation: Rule Per Company: Yes COMPANY AMOUNT DATE PROCESSED TRANSACTION # NCCI $ /27/ PDF Pipeline for SERFF Tracking Number NCCI Generated 12/12/ :15 AM

5 SERFF Tracking Number: NCCI State: Nevada Filing Company: NCCI State Tracking Number: Company Tracking Number: U-1398 (LW) TOI: 16.0 Workers Compensation Sub-TOI: Standard WC Product Name: U-1398 Revisions to Statistical Plan for Workers Compensation and Employers Liability Insurance Project Name/Number: / Correspondence Summary Dispositions Status Created By Created On Date Submitted Approved Mr. Gennady Stolyarov II 12/12/ /12/2011 Objection Letters and Response Letters Objection Letters Response Letters Status Created By Created On Date Submitted Responded By Created On Date Submitted Pending Industry Response Mr. Gennady Stolyarov II 11/04/ /04/2011 Robert Dalton 12/12/ /12/2011 PDF Pipeline for SERFF Tracking Number NCCI Generated 12/12/ :15 AM

6 SERFF Tracking Number: NCCI State: Nevada Filing Company: NCCI State Tracking Number: Company Tracking Number: U-1398 (LW) TOI: 16.0 Workers Compensation Sub-TOI: Standard WC Product Name: U-1398 Revisions to Statistical Plan for Workers Compensation and Employers Liability Insurance Project Name/Number: / Disposition Disposition Date: 12/12/2011 Effective Date (New): Effective Date (Renewal): Status: Approved Comment: Rate data does NOT apply to filing. PDF Pipeline for SERFF Tracking Number NCCI Generated 12/12/ :15 AM

7 SERFF Tracking Number: NCCI State: Nevada Filing Company: NCCI State Tracking Number: Company Tracking Number: U-1398 (LW) TOI: 16.0 Workers Compensation Sub-TOI: Standard WC Product Name: U-1398 Revisions to Statistical Plan for Workers Compensation and Employers Liability Insurance Project Name/Number: / Schedule Schedule Item Schedule Item Status Public Access Supporting Document Authorization Letter Yes Supporting Document Filing Fees Yes Supporting Document Filing Memorandum Yes Supporting Document Workers' Compensation Rate Filing/Loss Yes Costs Expense Worksheet Supporting Document Response to Objection Yes Rate Exhibit 1 Yes Rate Exhibit 2 Yes Rate Exhibit 3 Yes Rate Exhibit 4 Yes Rate Exhibit 5 Yes Rate Exhibit 6 Yes Rate (revised) Exhibit 7 Yes Rate Exhibit 7 Yes Rate Exhibit 8 Yes PDF Pipeline for SERFF Tracking Number NCCI Generated 12/12/ :15 AM

8 SERFF Tracking Number: NCCI State: Nevada Filing Company: NCCI State Tracking Number: Company Tracking Number: U-1398 (LW) TOI: 16.0 Workers Compensation Sub-TOI: Standard WC Product Name: U-1398 Revisions to Statistical Plan for Workers Compensation and Employers Liability Insurance Project Name/Number: / Objection Letter Objection Letter Status Pending Industry Response Objection Letter Date 11/04/2011 Submitted Date 11/04/2011 Respond By Date 01/04/2012 Dear Maggie Karpuk, Thank you for your filing submission. This filing has been assigned to me today, and I have had the opportunity to review it. I have one item of concern, and this filing is hereby disapproved, pending NCCI's response. Please feel free to contact me if you would like any clarification regarding the inquiry below. Objection 1 - Filing Memorandum (Supporting Document) - Exhibit 4, Loss & Expense Information (Rate) - Exhibit 6, Coding Values (Rate) Comment: Please explain the rationale for removing the category of "partially fraudulent" claims. According to the prior definition (including the Nevada-specific clarification in Exhibit 6, page 16), the ruling of a court, authorized workers' compensation agency, or other authorized adjudicator is determinative with respect to whether or not a claim is fully fraudulent or partially fraudulent. It still appears to be possible that one of the entities above would define a claim as partially fraudulent. Furthermore, it still appears possible to have a claim where an actual injury occurred, so some of the costs associated with that injury are legitimate, while others of the costs claimed have been found invalid, unnecessary, or excessive. Is NCCI making the assumption that a "partially fraudulent" determination will not be made in any jurisdiction? I would appreciate a clarification of the thinking that led to this particular proposal. This filing will be closed if no response is received within 60 days. If you have any questions, please feel free to contact me by phone or . Sincerely, Mr. Gennady Stolyarov II PDF Pipeline for SERFF Tracking Number NCCI Generated 12/12/ :15 AM

9 SERFF Tracking Number: NCCI State: Nevada Filing Company: NCCI State Tracking Number: Company Tracking Number: U-1398 (LW) TOI: 16.0 Workers Compensation Sub-TOI: Standard WC Product Name: U-1398 Revisions to Statistical Plan for Workers Compensation and Employers Liability Insurance Project Name/Number: / Response Letter Response Letter Status Submitted to State Response Letter Date 12/12/2011 Submitted Date 12/12/2011 Dear Mr. Gennady Stolyarov II, Comments: Response 1 Comments: Attached is the repsonse to the Objection and the revised exhibit 7. Related Objection 1 Applies To: - Filing Memorandum (Supporting Document) - Exhibit 4, Loss & Expense Information (Rate) - Exhibit 6, Coding Values (Rate) Comment: Please explain the rationale for removing the category of "partially fraudulent" claims. According to the prior definition (including the Nevada-specific clarification in Exhibit 6, page 16), the ruling of a court, authorized workers' compensation agency, or other authorized adjudicator is determinative with respect to whether or not a claim is fully fraudulent or partially fraudulent. It still appears to be possible that one of the entities above would define a claim as partially fraudulent. Furthermore, it still appears possible to have a claim where an actual injury occurred, so some of the costs associated with that injury are legitimate, while others of the costs claimed have been found invalid, unnecessary, or excessive. Is NCCI making the assumption that a "partially fraudulent" determination will not be made in any jurisdiction? I would appreciate a clarification of the thinking that led to this particular proposal. Changed Items: Supporting Document Schedule Item Changes Satisfied -Name: Response to Objection Comment: PDF Pipeline for SERFF Tracking Number NCCI Generated 12/12/ :15 AM

10 SERFF Tracking Number: NCCI State: Nevada Filing Company: NCCI State Tracking Number: Company Tracking Number: U-1398 (LW) TOI: 16.0 Workers Compensation Sub-TOI: Standard WC Product Name: U-1398 Revisions to Statistical Plan for Workers Compensation and Employers Liability Insurance Project Name/Number: / No Form Schedule items changed. Rate/Rule Schedule Item Changes Exhibit Name Rule # or Page # Rate Action Previous State Filing # Exhibit 7 State Special New Previous Version Exhibit 7 State Special New Sincerely, Alison Herwig, Frank Gnolfo, Lesley O'Brien, Maggie Karpuk, Robert Dalton, karin Steger Rate/Rule Schedule Schedule Item Exhibit Name: Rule # or Page Rate Action Previous State Filing Attachments Status: #: Number: Exhibit 1 General Rules Replacement U-1397 U Exhibit 1.pdf Exhibit 2 Header/Policy Information Replacement U-1397 U Exhibit 2.pdf Exhibit 3 Exposure Information Replacement U-1397 U Exhibit 3.pdf Exhibit 4 Loss & Expense Replacement U-1397 U Exhibit 4.pdf Information Exhibit 5 Correction Infomation Replacement U-1397 U Exhibit 5.pdf Exhibit 6 Coding Values Replacement U-1397 U Exhibit 6.pdf Exhibit 7 State Special New Amended Nevada PDF Pipeline for SERFF Tracking Number NCCI Generated 12/12/ :15 AM

11 SERFF Tracking Number: NCCI State: Nevada Filing Company: NCCI State Tracking Number: Company Tracking Number: U-1398 (LW) TOI: 16.0 Workers Compensation Sub-TOI: Standard WC Product Name: U-1398 Revisions to Statistical Plan for Workers Compensation and Employers Liability Insurance Project Name/Number: / Exception Pages- Exhibit 7.pdf Exhibit 8 General Explanations Replacement E-1400 U Exhibit 8.pdf PDF Pipeline for SERFF Tracking Number NCCI Generated 12/12/ :15 AM

12 PAGE 6 EXHIBIT 1 PART 1 GENERAL RULES B. PREPARATION AND COMPLETION OF UNIT STATISTICAL REPORTS Summarized exposure, premium, and loss data for each workers compensation policy is required under Item F of this part. N C C I s t r o n g l y e n c o u r a g e s d a t a p r o v i d e r s t o Data providers must report data in the electronic format for unit statistical data received on and after January 1, Refer to NCCI's Electronic Transmission User's Guide for additional information regarding electronic reporting. W h e n e l e c t r o n i c r e p o r t i n g i s n o t f e a s i b l e, N C C I p e r m i t s s t a t i s t i c a l d a t a t o b e r e p o r t e d o n h a r d c o p y f o r m s.

13 PAGE 7 EXHIBIT 1 (CONT'D) PART 1 GENERAL RULES C. T R A N S M I T T A L L E T T E R S APPLICATION OF MANUAL RULES T h e fi l i n g o f s t a t i s t i c a l d a t a o n m e d i a, o t h e r t h a n e l e c t r o n i c d a t a t r a n s f e r r e d t h r o u g h t h e I n t e r n e t, m u s t b e a c c o m p a n i e d b y t r a n s m i t t a l l e t t e r s s h o w i n g s u m m a r y t o t a l s. Rules apply separately to each unit report, including its associated exposure and corresponding claims The effective date of a rule or a change in any rule is the date approved for use by the insurance department NCCI s Unit Statistical Reporting Guidebook provides supplemental information and examples for reporting accurate and timely unit statistical data to NCCI The application of payroll and losses used to calculate a risk s experience modification is in accordance with NCCI s Experience Rating Plan Manual Classification code assignment and basis of premium are determined in accordance with NCCI s Basic Manual

14 PAGE 8 F. FILING REQUIREMENT EXHIBIT 1 (CONT'D) PART 1 GENERAL RULES Exposure, premium, and loss data must be filed for every policy governed under the scope of this Plan. Statistical data must not be reported for the following types of policies: Employers liability insurance on residence and farm employees provided in conjunction with other liability insurance. Workers compensation on domestic workers provided in conjunction with homeowners insurance. Policies providing coverage under the National Defense Projects Rating Plan. Policies providing coverage on Nuclear Regulatory Commission projects. Policies providing excess coverage.

15 PAGE 9 G. FILING OF STATISTICAL DATA EXHIBIT 1 (CONT'D) PART 1 GENERAL RULES Electronic reports or transmissions must be submitted to NCCI. Refer to NCCI's Electronic Transmission User's Guide for further information i n s t r u c t i o n. E x p o s u r e, p r e m i u m, a n d l o s s d a t a s u b m i t t e d o n h a r d c o p y f o r m s m u s t b e fi l e d d i r e c t l y w i t h t h e k e y i n g v e n d o r a c c o r d i n g t o t h e p r o c e d u r e s i n N C C I ' s U n i t S t a t i s t i c a l R e p o r t i n g G u i d e b o o k. A l l r e p o r t s, l a b e l s, a n d t r a n s m i t t a l s m u s t b e t y p e d o r c l e a r l y p r i n t e d w i t h b l u e o r b l a c k i n k.

16 PAGE 10 EXHIBIT 1 (CONT'D) PART 1 GENERAL RULES H. STATE FILING REQUIREMENTS F O R M U L T I S T A T E P O L I C I E S D a t a m u s t b e fi l e d f o r e a c h s t a t e o f a m u l t i s t a t e p o l i c y i n a c c o r d a n c e w i t h t h e s c o p e o f t h i s P l a n. A r e p o r t m u s t b e fi l e d f o r e a c h s t a t e o n a p o l i c y w i t h e s t i m a t e d e x p o s u r e, i n c l u d i n g t h o s e f o r w h i c h n o e x p o s u r e w a s d e v e l o p e d. H o w e v e r, i f a s t a t e w a s w r i t t e n o n a n I f A n y b a s i s, a r e p o r t i s n o t r e q u i r e d p r o v i d e d n o e x p o s u r e d e v e l o p e d f o r t h a t s t a t e. 1. Single-State Policy Unit statistical data is required to be reported for a single-state policy when any of the following apply: Developed exposure at audit Not yet been audited (estimated exposure) Developed no exposure at audit a. Policy With No Exposure Developed For a policy that developed no exposure at audit, report Statistical Code 1111 No Exposure Developed, along with the applicable expense constant and balance to minimum premium. 2. Multistate Policy Unit statistical data is required to be reported for any state on the policy when any of the following apply: Developed exposure at audit Not yet been audited (estimated exposure) Developed no exposure at audit after estimated exposure was reported on the policy Developed exposure, after being written on an if any basis a. If Any State on Policy With No Exposure Developed Unit statistical data is not reported for a state when all of the following apply: Written on an If Any basis the policy was issued with no exposure in that state No exposure developed at audit The applicable expense constant does not apply in that state The applicable policy minimum premium does not apply in that state

17 PAGE 11 EXHIBIT 1 (CONT'D) PART 1 GENERAL RULES L. COAL MINE AND BLACK LUNG DISEASE EXPERIENCE T h e f o l l o w i n g s p e c i a l r e p o r t i n g r e q u i r e m e n t s a p p l y t o c o a l m i n e e x p e r i e n c e : Experience incurred for underground and surface coal mine operators, which are classified in accordance with the Basic Manual, and any risks exposed to Black Lung Disease (also known as Coal Workers Pneumoconiosis) must be filed according to the rules of this Plan. 1. U n d e r g r o u n d C o a l M i n e R i s k s Reporting of Classification Code and Corresponding Statistical Code E x p e r i e n c e i n c u r r e d f o r u n d e r g r o u n d c o a l m i n e p o l i c i e s, w h i c h a r e c l a s s i fi e d i n a c c o r d a n c e w i t h t h e B a s i c M a n u a l f o r W o r k e r s C o m p e n s a t i o n a n d E m p l o y e r s L i a b i l i t y I n s u r a n c e ( B a s i c M a n u a l ), m u s t b e fi l e d a c c o r d i n g t o t h e r u l e s o f t h i s P l a n. T h i s i n c l u d e s a l l i n s u r e d u n d e r g r o u n d c o a l m i n e o p e r a t i o n s, i n c i d e n t a l o p e r a t i o n s, a n d o p e r a t i o n s o t h e r t h a n u n d e r g r o u n d c o a l m i n i n g o f a n y o n e e m p l o y e r. Experience for traumatic and occupational disease, other than Black Lung Disease, must be reported with the applicable classification code. Black Lung Disease experience for state and/or federal acts must be reported separately from the classification code under the corresponding statistical code. Following are the classification codes along with their corresponding statistical codes for Black Lung Disease: Classification Code 1016 Coal Mining NOC 1005 Coal Mining Surface and Drivers Any non-coal mining classification code Statistical Code 0158 Black Lung Disease Experience in Connection With Code Black Lung Disease Experience in Connection With Code Black Lung Disease Experience in Connection With Any Classification Other Than Coal Mine Code a. A d v a n c e R e p o r t s ( I n c l u d i n g S i x - M o n t h E x p e r i e n c e ) T o c o m p l e t e a n a d v a n c e e x p e r i e n c e r a t i n g f o r a n u n d e r g r o u n d c o a l m i n e p o l i c y, a n a d v a n c e r e p o r t o f t h e fi r s t s i x m o n t h s ' e x p e r i e n c e o f t h e c u r r e n t p o l i c y m u s t b e fi l e d d i r e c t l y w i t h N C C I ' s C u s t o m e r S e r v i c e E x p e r i e n c e R a t i n g D e p a r t m e n t. S u c h a d v a n c e r e p o r t i n g m u s t b e fi l e d n o l a t e r t h a n 7 5 d a y s p r i o r t o t h e a n n i v e r s a r y r a t i n g d a t e. E x p o s u r e a n d i n c u r r e d l o s s e s f o r t h e fi r s t s i x m o n t h s o n l y o f t h e c u r r e n t p o l i c y m u s t b e i n c l u d e d i n t h i s a d v a n c e r e p o r t, a n d l o s s e s m u s t b e v a l u e d t h r e e m o n t h s p r i o r t o t h e a n n i v e r s a r y r a t i n g d a t e. T h e s e a d v a n c e r e p o r t i n g s a r e e n t i r e l y i n d e p e n d e n t o f N C C I ' s S t a t i s t i c a l P l a n fi l i n g s, a n d t h e e x p e r i e n c e m u s t b e r e p o r t e d w h e n d u e u n d e r t h e r e q u i r e m e n t s o f t h i s P l a n. b. T r a u m a t i c I f t h e t r a u m a t i c r a t e f o r t h e u n d e r g r o u n d c o a l m i n e c l a s s c o d e c o n t a i n s a c a t a s t r o p h e l o a d i n g t h a t i s n o t s u b j e c t t o e x p e r i e n c e m o d i fi c a t i o n, t h e n r e p o r t t h e a u t h o r i z e d r a t e a f t e r a d j u s t i n g f o r t h e n o n r a t a b l e c a t a s t r o p h e l o a d i n g p r i o r t o e x p e r i e n c e m o d i fi c a t i o n. T h e f o l l o w i n g f o r m u l a s h o u l d b e u s e d t o o b t a i n t h e a d j u s t e d a u t h o r i z e d r a t e : S u b j e c t R a t e = T r a u m a t i c R a t e C a t a s t r o p h e R a t e

18 PAGE 12 EXHIBIT 1 (CONT'D) PART 1 GENERAL RULES A u t h o r i z e d R a t e = S u b j e c t R a t e x E x p e r i e n c e M o d i fi c a t i o n + C a t a s t r o p h e R a t e R e f e r t o N C C I ' s U n i t S t a t i s t i c a l R e p o r t i n g G u i d e b o o k f o r a d d i t i o n a l i n f o r m a t i o n. 2. D i s e a s e E x p e r i e n c e f o r C o a l M i n e R i s k s Reporting of Experience for Federal Act Only R e p o r t t h e p r e m i u m f o r d i s e a s e a f t e r t h e a p p l i c a t i o n o f t h e e x p e r i e n c e m o d i fi c a t i o n f a c t o r w i t h t h e a p p r o p r i a t e e x p o s u r e c o v e r a g e c o d e. R e f e r t o P a r t 3, I t e m D E x p o s u r e C o v e r a g e C o d e f o r t h e d e fi n i t i o n o f e x p o s u r e c o v e r a g e c o d e. D i s e a s e e x p e r i e n c e m u s t b e r e p o r t e d f o r d i s e a s e i n c o n n e c t i o n w i t h a n y c o a l m i n e c l a s s i fi c a t i o n i n a c c o r d a n c e w i t h t h e B a s i c M a n u a l o r f o r a n y c l a s s c o d e o t h e r t h a n c o a l m i n i n g w h e r e t h e r e i s l i a b i l i t y u n d e r t h e F e d e r a l C o a l M i n e H e a l t h a n d S a f e t y A c t. If Black Lung Disease coverage has been provided under the Federal Coal Mine Health and Safety Act only without state act coverage, experience for the Black Lung Disease must be reported under Statistical Code 0164 (Black Lung Disease Experience for Federal Benefits Only). Exposure Act/Exposure Coverage Code 03 and Loss Condition Act Code 03 (Coverage Under the Federal Coal Mine Health and Safety Act Only) must also be used when reporting the exposure, premium, and corresponding losses. 3. Reporting of Traumatic and Occupational Disease Experience (Other Than Black Lung Disease) a. Exposure and losses for traumatic and occupational disease experience, other than Black Lung Disease, must be reported under the applicable classification code. The appropriate Exposure Act/Exposure Coverage and Loss Condition Act codes must also be reported for the classification code. Note: Exposure Act/Exposure Coverage Codes 03 and 04 are not valid. Note: Assignment of Injury Description Code Nature of Injury that represents the traumatic or Non-Black Lung Disease claim must also be reported appropriately. Nature of Injury Code 62 Black Lung is not valid for these claims. 4. Reporting of Black Lung Disease (Coal Workers Pneumoconiosis) Experience Black Lung Disease experience reporting requirements are as follows: a. Exposure and Premium Exposure and premium charged for Black Lung Disease coverage under State Act and/or Federal Coal Mine Health and Safety Act are reported separately from the classification code(s) manual premium. Black Lung Disease premium is not subject to experience rating, premium discounts, or retrospective rating, and it is not included in the Standard Premium. Black Lung Disease exposure and premium must be reported under the appropriate statistical code as follows, based on the following coverage provided on the policy: State Act only coverage Use Exposure Act/Exposure Coverage Code (01) State Act or Federal Act Excluding USL&HW and Federal Coal Mine Health and Safety Act

19 PAGE 13 EXHIBIT 1 (CONT'D) PART 1 GENERAL RULES Federal Act only coverage Use Exposure Act/Exposure Coverage Code (03) Coverage Under the Federal Coal Mine Health and Safety Act Only Federal and State Act coverage Use Exposure Act/Exposure Coverage Code (04) Coverage Under the Federal Coal Mine Health and Safety Act and the State Act b. Losses Losses resulting from Black Lung Disease coverage under State Act and/or Federal Coal Mine Health and Safety Act are reported separately from the classification code. Black Lung Disease losses must be reported under the appropriate statistical code as follows, based on the following benefits paid or payable under the policy: State Act only benefits Use Loss Condition Act Code (01) State Act or Federal Act Excluding USL&HW and Federal Coal Mine Health and Safety Act Federal Act only benefits Use Loss Condition Act Code (03) Coverage Under the Federal Coal Mine Health and Safety Act Only Federal and State Act benefits Use Loss Condition Act Code (04) Coverage Under the Federal Coal Mine Health and Safety Act and the State Act Note: Assignment of Injury Description Code Nature of Injury that represents the Black Lung Disease claim must also be reported appropriately.

20 PAGE 14 R. EXCESS POLICIES EXHIBIT 1 (CONT'D) PART 1 GENERAL RULES Exposure and losses for excess policies must not be reported.

21 PAGE 15 D. REPLACEMENT REPORT CODE EXHIBIT 2 PART 2 HEADER/POLICY INFORMATION Identify reports being submitted to replace a report that was previously submitted. The replacement indicator may only be submitted for the first reporting of exposure, premium, and loss data valued 18 months after the policy effective date. Refer to Item Q Original Administration Number IdentifierP e n d i n g F i l e N u m b e r in this part for Replacement Report processing information. Refer to NCCI's Unit Statistical Reporting Guidebook for additional information.

22 PAGE 16 EXHIBIT 2 (CONT'D) PART 2 HEADER/POLICY INFORMATION L. P A G E N U M B E R ( H A R D C O P Y O N L Y ) LINK DATA FIELDS R e p o r t t h e p a g e n u m b e r o f m u l t i p a g e h a r d c o p y r e p o r t s ( e. g., p a g e 1 o f X ). N o t r e q u i r e d o n s i n g l e - p a g e h a r d c o p y r e p o r t s. Link data fields must be the same on all corresponding records for each unit report. The link data fields are Carrier Code, Policy Number, Exposure State Code, Report Number, and Correction Sequence Number.

23 PAGE 17 EXHIBIT 2 (CONT'D) PART 2 HEADER/POLICY INFORMATION M. L A S T P A G E N U M B E R ( H A R D C O P Y O N L Y ) KEY FIELDS R e p o r t t h e l a s t p a g e n u m b e r o f m u l t i p a g e h a r d c o p y r e p o r t s ( e. g., p a g e X o f 5 ). N o t r e q u i r e d o n s i n g l e - p a g e h a r d c o p y r e p o r t s. For each state on a policy, the key fields must be the same across all report levels including corresponding corrections. Key fields are Carrier Code, Policy Number Identifier, Policy Effective Date, and Exposure State Code. If any key fields require corrections, they must be applied as follows: For Carrier Code, Policy Number Identifier, and/or Policy Effective Date, report a correction to the 1st report only. Report the revised key field(s) being corrected and the previous reported value (Previous Carrier Code, Previous Policy Number Identifier, and Previous Policy Effective Date). For Exposure State Code only or in combination with other key fields, report a correction to remove all exposure and losses at every report level, and report new original unit report(s) with the correct values.

24 PAGE 18 EXHIBIT 2 (CONT'D) PART 2 HEADER/POLICY INFORMATION Q. P E N D I N G F I L E N U M B E R ORIGINAL ADMINISTRATION NUMBER IDENTIFIER Report the p e n d i n g fi l e n u m b e r original administration number identifier assigned by NCCI when submitting a replacement report to NCCI.

25 PAGE 19 EXHIBIT 3 PART 3 EXPOSURE INFORMATION H. SPLIT PERIOD CODE ( E L E C T R O N I C R E P O R T I N G O N L Y ) Report when indicating changes in rates or experience modification during a policy period. Valid values are 0 9, where 0 is reported for the first effective period, 1 is reported for the second effective period, and so on through the ninth effective period (if applicable). This field is zero-filled for policies with no changes in rates or experience modification.

26 PAGE 20 S. EXPENSE CONSTANT A M O U N T EXHIBIT 3 (CONT'D) PART 3 EXPOSURE INFORMATION R e p o r t t h e a p p r o v e d e x p e n s e c o n s t a n t s e p a r a t e l y f r o m c l a s s i fi c a t i o n c o d e e x p o s u r e s a n d p r e m i u m s u n d e r t h e d e s i g n a t e d s t a t i s t i c a l c o d e. T h i s p r e m i u m m u s t n o t b e i n c l u d e d i n t h e s t a n d a r d p r e m i u m. The expense constant applicable to a single or multistate policy is reported under Statistical Code 0900 and reported separately from the classification code(s) manual premium and any Balance to Minimum Premium. The expense constant amount is not included in the Standard Premium. The expense constant on a multistate policy must be allocated to the state with the highest expense constant applicable. If two or more states included on the policy have the same highest expense constant, the expense constant must be reported for the state with the highest expense constant and largest amount of standard premium. Refer to NCCI's Basic Manual for additional rules.

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