WORKER S COMPENSATION AND EMPLOYERS LIABILITY INSURANCE

Transcription

1 WCRB Wisconsin Compensation Rating Bureau WISCONSIN WORKERS COMPENSATION STATISTICAL PLAN MANUAL WORKER S COMPENSATION AND EMPLOYERS LIABILITY INSURANCE Effective April 17, 2012 SUMMARY OF CHANGES issued by: Wisconsin Compensation Rating Bureau Swenson Drive, Suite 100 Waukesha, WI Contains Materials Copyrighted by the National Council on Compensation Insurance, Inc Used with Permission. All Rights Reserved.

2 WI STATISTICAL PLAN MANUAL CONTENTS I. INTRODUCTION II. III. IV. WISCONSIN REPORTING REQUIREMENTS CODES GLOSSARY V. SAMPLE FORMS VI. ELECTRONIC SUBMISSION NOTABLE CHANGES WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 2 OF 48

3 I. INTRODUCTION This Plan contains the necessary instructions for the reporting of experience on the direct business, (voluntary and assigned risk), written by the data provider for Worker s Compensation and Employers Liability Insurance in Wisconsin. While this Manual refers to electronic filing, instructions for electronic filing of unit statistical reports can be found in the WCIO Workers Compensation Data Specifications Manual located on the Workers Compensation Insurance Organizations (WCIO) Web site. The Wisconsin Compensation Rating Bureau will hereinafter be referred to as "the Bureau", or WCRB. Schedule for Filing Unit Report Data The instructions set forth in this Plan are applicable to all reports for policies effective on or after January 1, 1996 for experience on: 1 st reports due on and after July 1, nd reports due on and after July 1, rd reports due on and after July 1, th reports due on and after July 1, th reports due on and after July 1, 2001 Expanded reporting to add 6 th through 10 th reports for policies effective on or after January 1, 1999: 6 th reports due on and after July 1, th reports due on and after July 1, th reports due on and after July 1, th reports due on and after July 1, th reports due on and after July 1, 2009 The following table outlines the valuation month and report month for each policy effective month. Policy Effective Month Valuation Month 18 Months After Policy Effective Month Report Month 20 Months After Policy Effective Month January July September February August October March September November April October December May November January June December February July January March August February April September March May October April June November May July December June August WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 3 OF 48

4 I. INTRODUCTION (cont'd) Bureau Correspondence Delinquent Letter Delinquent letters are created when a unit report is due and the report is not in WCRB s database in an Accepted status. NOTE: The requirement for filing a unit statistical report is met only when the report is in an Accepted status in Manage USR. Reject Letter The Reject Letter identifies the edit failures causing the unit report to fail in WCRB s database, as well as the type of report (correction or replacement) required to fix the error. NOTE: This documentation serves as the 1 st Notice that we expect to receive another unit report to resolve the documented edit failures. Estimated Unit Report Letter The Estimated Unit Report Letter is created when a unit report is received and in an Accepted status in Manage USR and the Policy Condition Indicator-Estimated Audit Code is a Y. (See section II. A. 2 for filing requirements) Electronic notification of Bureau correspondence can be obtained by completing and submitting the Unit Statistical Letter Notification Preference form, found in the Forms tab of the WCRB Web site. All letter types are posted on the WCRB Web site ( in Manage USR. Schedule of Statistical Plan Fines WCRB is authorized to levy fines for delinquent unit reports. The schedule for fining is as follows: Notice Amount 1 st $ 0 2 nd $ rd $ th $ th and all subsequent $ 500 Failure to comply may result in a letter of complaint being issued to the Office of the Commissioner of Insurance for the State of Wisconsin. The fine schedule was approved by the Office of the Commissioner of Insurance for the State of Wisconsin to be effective January 1, Statistical Plan Summary of Changes Changes to the Wisconsin Statistical Plan Manual will be listed in the Summary of Changes document released with each Manual revision. WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 4 OF 48

5 I. INTRODUCTION (Cont'd) GENERAL RULES/DEFINITIONS A. Scope of Report Final audited statistical data must be filed for every policy insuring liability under Wisconsin Worker s Compensation and Employers Liability Insurance. Two reporting options exist when reporting unit statistical data for Wisconsin effective July 1, All unit reports must be filed using either Option I or Option 2 as defined below: Option 1: Electronically file all unit statistical report data directly with the WCRB through CDX (Compensation Data Exchange), found on the accct.org Web site. Prior to submitting unit statistical data directly to WCRB, a Filing Option Election Form must be completed and sent to WCRB for approval. (Copy of form in V. Sample Forms) Contact WCRB directly for questions regarding reporting requirements and the method for submission. Option 2: If you are not approved to file directly with WCRB, all reports must be filed electronically with the National Council on Compensation Insurance Inc. (NCCI), Data Center Processing Team, 901 Peninsula Corporate Circle, Boca Raton, FL B. Recording of Statistics Unit statistical reports consist of experience comprising exposure and loss data for Wisconsin businesses. Electronic reporting specifications are published in the WCIO Workers Compensation Data Specifications Manual found on the WCIO Web site at wcio.org. These specifications are maintained and published by the WCIO. The Bureau Entry and Edit Package (BEEP) is available for the electronic reporting of unit statistical data for Wisconsin. Additional information regarding BEEP can be found on the accct.org Web site. C. Multiple Year Policies Multiple year policies, other than three-year fixed rate policies, shall be considered as separate annual policies for reporting purposes and reports for each unit of 12 months or less shall be filed at the time all other reports on policies with the same effective date are being filed. Losses shall be valued as of the 18th month after the month in which each unit of experience became effective and at annual periods thereafter. Examples: 1. The reports on a three-year policy effective January 1, 2006 shall be filed with regular reports on policies effective January 1, 2006, January 1, 2007, and January 1, First report valuations shall be as of July 2007, July 2008, and July 2009, respectively. 2. The reports on a policy covering the period January 1, 2006 to July 1, 2007, with the first six months considered as a unit, shall be filed with the regular reports on policies effective January 1, 2006 and July 1, Losses shall be valued as of July 2007 and January 2008, respectively. WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 5 OF 48

6 I. INTRODUCTION (cont'd) 3. The reports on a policy covering the period January 1, 2006 to July 1, 2008, with the last six months considered as a unit, shall be filed with the regular reports on policies effective January 1, 2006, January 1, 2007, and January 1, Losses shall be valued as of July 2007, July 2008, and July 2009, respectively. D. Uncollectible Premiums and Corresponding Losses All earned premiums, whether collectible or not, shall be reported. Likewise, the corresponding exposure and losses shall be reported. E. Radiation Exposure-Other Than Government Agency Atomic Energy Projects Experience in connection with Atomic Energy Projects performed for, or under the direction of, any government agency shall be excluded from the experience reported under this Plan. This Manual provides that a supplemental rate, subject to the approval of the Bureau, may be applied to operations involving research, manufacturing, handling, transportation, use of or exposure to radioactive materials, where such operations are not performed for or under the direction of any government agency. The payroll to which such supplemental rate is applicable, together with the premium derived from such charge, shall be reported under Classification Code The payroll reported for Classification Code 9985 shall be reported in the Exposure Amount field and shall not be added to payrolls shown for other manual classifications in determining the risk s Exposure Amount Total amount. The Exposure Amount, Manual/Charged Rate, and Premium Amount are not subject to experience modification and only the premium shall be included in the risk total. Similarly, radiation losses on risks where a supplemental loading has been applied shall be assigned to Classification Code If no supplemental radiation loading has been applied, any radiation losses shall be assigned to the appropriate classification. Note, however, that any radiation loss, whether reported under Classification Code 9985 or a regular classification, must be identified as a disease loss in the field named Loss Conditions. Refer to section III. C.4. Loss Conditions. F. Reinsurance No deductions shall be made from earned premiums and incurred losses for, or on account of, reinsurance ceded. Premiums earned and losses incurred on account of reinsurance received by the reporting data provider shall be excluded from the experience. G. Excess Insurance Experience on Excess Insurance policies must be excluded from the experience reported under this Plan. H. Experience Under the National Defense Projects Rating Plan Any portion of exposure resulting from experience written under the National Defense Projects Rating Plan shall not be included as audited exposure in the insured s statistical filing. I. Admiralty and Federal Employers Liability The Bureau has no jurisdiction over the rates and classifications for Admiralty or Federal Employers Liability exposure. Admiralty and Federal Employers Liability exposure shall be excluded from the experience reported under this Plan. WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 6 OF 48

7 I. INTRODUCTION (cont'd) J. Loss Rules 1. Occupational Disease Incurred Losses a. Disease losses shall be identified in the Loss Conditions Codes/Type of Loss field by the appropriate code for Disease Loss according to section III. C.4. Loss Conditions. The total losses reported shall be the total of traumatic losses and disease losses incurred and shall exclude any allocated claim expense, but shall include allocated claim expense for Part II Employers Liability losses. b. Dust disease losses incurred in connection with payrolls reported under Classification Code 0066 shall likewise be assigned to the same code and shall be further identified by the appropriate code for Disease Loss in the Loss Conditions Codes/Type of Loss field. These losses shall also be included in the total losses reported. 2. Interest on Awards Interest on awards for delayed payments of compensation due, for which the data provider is liable and which accrue as benefits to the injured worker or his dependents, shall be chargeable to losses and so reported. No penalties or fines are to be charged to losses. 3. Medical on Compensable Cases Medical losses shall include all payments to doctors and hospitals as well as physical rehabilitation costs and reserves for future payments but shall not include any claim expense. In this connection, see the instructions contained in J.7. of this section. 4. Subrogation Claims a. For subrogation cases, the net liability shall be determined by deducting from the incurred cost prior to recovery the amount recovered through subrogation less any expenses incurred in connection with such recovery. However, in cases where the expenses incurred in connection with such recovery exceed the amount recovered, the net amount of losses reported shall not exceed the gross amount of loss prior to recovery. Furthermore, the net liability incurred shall be apportioned to indemnity and medical as recovered in the settlement. If apportionment of the credit to the claim is not identified, a suggested method for apportionment is given below. Subrogation correction reports are required to be filed for all report levels where the subrogation claim has been previously reported. Each report level should be corrected to reflect the change in loss due to the subrogation recovery. b. When a subrogation recovery is received by the data provider subsequent to the first reporting of the claim, a correction report must be filed with the Bureau reducing the incurred loss on the claim by the amount of the subrogation recovery received. WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 7 OF 48

8 I. INTRODUCTION (cont d) A suggested method for these calculations is given in the following example: Total Ind % of Total Med % of Total Gross Incurred Loss $20,000 $17, $3, Subrogation Received $ 7,000 Claim Expense $ 500 Net Recovery $ 6,500 Net Loss $13,500 $11, $2, c. When subrogation is final and claim is closed, report the net loss. In the event the net loss is greater than what was previously reported, no correction may be filed. 5. Aircraft Operation Losses Losses incurred in connection with employees of the risk, other than members of the flying crew, shall not be reported by classification but shall be assigned to Statistical Code 9108, provided such losses arise out of the operation of aircraft subject to a passenger seat surcharge. NOTE: The passenger seat surcharge is not applicable for policies effective January 1, 2015 and subsequent. 6. Subsequent Reports The rules of this section apply to any second through tenth report involving (1) claim reported "open" on the previous report, (2) any re-opened claim reported "closed" on the previous report, (3) any claim previously unreported, or (4) any other change in the valuation of losses. The data reported for each claim shall be the previously reported and the revised values. It shall not be permissible to revise loss values between two valuation dates because of departmental or judicial decision, or because of developments in the nature of the injury. 7. Medical or Legal Expense Medical or legal expenses incurred for the benefit of the data provider to secure evidence for presentation before an official body shall be treated as adjusting expenses and not reported except as respects Employers Liability, Part II, of the Worker s Compensation Policy. The following are a few examples that should be charged to expenses rather than to losses: a. Medical examination of a claimant on behalf of the data provider to determine liability. b. Cost of securing birth and death certificates. c. Cost of performing autopsies. d. Expert testimony of physicians on behalf of the data providers or fees paid to the claimant's physician called in by the data provider. WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 8 OF 48

9 I. INTRODUCTION (cont'd) NOTE: When the claimant calls in the attending physician to give medical testimony on the claimant s behalf, or where the data provider is required to produce the claimant's physician at the hearing and the employee or the data provider is required to pay such a physician's fee, the payment of the fee shall be reported as a medical loss. When an award to a claimant includes the cost of witness fees, attorney fees, and other court costs, the amount so awarded shall be considered as part of the cost of the benefit and shall be included with the indemnity reported. With respect to claims brought by persons against whom an employee has brought a third party common law action, such special costs shall be reported as an indemnity loss whether or not a recovery is made against the third party by the employee. See section IV. Glossary for more information. 8. Incurred Losses Report the total of all paid plus outstanding compensation in the fields captioned Incurred Indemnity Amount and Incurred Medical Amount. Report the total of all paid compensation in the fields captioned Paid Indemnity Amount and Paid Medical Amount. The outstanding costs shall be the company's individual case estimates of future payments as of the date of valuation. a. When a final award has been made, the total incurred compensation must be in agreement with such award, except under the following circumstances: (1) When a claimant has appealed for a higher award for a compensable claim, the data provider shall report at least the amount of the award, but may report a higher amount if, in its judgment, the facts in the case indicate an additional reserve is advisable. (2) In cases where a claim has been officially declared non-compensable by a law judge, if the appeal has been taken and is undetermined on the valuation date, the data provider shall report the incurred cost that would have been reported had the claim not been declared non-compensable. It should not be reported as non-compensable during the appeals process. (3) In cases where a claim has been officially declared non-compensable, if the period during which an appeal may be taken has not expired by the valuation date, the data provider may report the incurred cost that would have been reported had there been no declaration of non-compensability. It shall be permissible to eliminate from the report the reserve for the non-compensable claim in any case where the period for taking an appeal has expired subsequent to the date of valuation, but prior to the date of filing of the report, without an appeal having been taken. b. The closing of a claim shall be regarded for the purpose of this rule as the equivalent of a specific official declaration of non-compensability under the following circumstances: (1) No claim was filed during the period provided by law and the data provider, therefore, closes the case. WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 9 OF 48

10 I. INTRODUCTION (cont'd) (2) The data provider has raised the issues of accident prior to the valuation date and continues to contest the claim on any such issues; and the claim is officially closed because of the claimant's non-appearance or failure to prosecute his claim without a ruling on the question of accident, notice or causal relation. c. Where the data provider has appealed against an award, it shall report the full amount of such award. Cases on which the data provider has filed a petition to terminate must not be reported as closed or non-compensable until the petition has been granted by a referee or the Bureau of Worker s Compensation of the Department of Workforce Development and all appeals are final. d. If the final award has not been made, but compensation for the injury is subject to a definite schedule of benefits, the provisions of the Law shall be reflected in the amount of compensation reported. In all other cases the amount reported should reflect the data provider's estimate of incurred cost in the light of all information available on the date of valuation. e. Expenses, any general allowances for contingencies, and any supplemental nonstatutory benefits not otherwise provided for in this Plan must be excluded. Precautionary reserves in excess of the amount shown on the final settlement receipt as filed, at completion of all compensation payments, with the Wisconsin Department of Workforce Development, or other body having jurisdiction over worker s compensation claims shall not be included in the amount of losses reported under the Statistical Plan. Vocational Rehabilitation costs and reserves for future payments shall be included as part of the amount reported as incurred indemnity. In all cases where a claim has been determined to be eligible for reimbursement to the data provider from a special fund (such as Second Injury Fund, etc.) the gross incurred cost of the claim (i.e., prior to any reimbursement) shall be reduced by the amount of any paid or anticipated recovery from such fund and the net incurred cost of the claim shall be reported. Anticipated recovery is defined for this purpose as the amount of recovery expected to be recovered from such funds based on the rules governing such funds or a binding agreement between such funds and the data provider on an amount, or percentage of the incurred cost, to be reimbursed to the data provider on a particular claim. When such an anticipated recovery becomes known by the data provider or when a recovery is paid to the data provider subsequent to the first reporting of the claim on the 18th month valuation date of the policy, a correction report must be filed with the Bureau reducing the incurred cost on the claim by the amount of the paid or anticipated recovery. K. Special Reportings Three-Year Fixed Rate Policies 1. The rules in this section relate to the reporting of experience incurred under three-year fixed rate policies, written in accordance with Part 1, Rule XI of the WI Basic Manual. WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 10 OF 48

11 I. INTRODUCTION (cont'd) a. Second through tenth reports on three-year fixed rate policies or per capita policies reported in accordance with this section are not required. b. The rules of this Manual apply to the reporting of the experience, except as supplemented by the following rules in this section. 2. Three-Year Fixed Rate Unit Reporting Instructions a. The complete three-year experience incurred under each policy shall be reported. For electronic submission instructions see WCIO Workers Compensation Data Specifications Manual. b. Losses included in the reporting of a given policy shall be valued as of the 42nd month after the month in which the policy became effective, and the reports shall be filed not later than 44 months after the month in which the policy became effective. These reportings shall be specifically identified as three-year fixed rate policy experience (this must be done by reporting code "Y" in the Three-Year Fixed Rate Policy Indicator of the Policy Conditions Indicators field in the Header Record) and shall be segregated and reported independently of the reportings of one-year policies. c. The data required shall be the data specified in this Manual. Expense Constant premium shall be assigned to Statistical Code If the Deposit Premium has been paid in advance, report only the net amount, i.e. the amount of one Expense Constant; if the premium has been paid in annual installments, report the amount of two Expense Constants. Cancelation penalty premium shall be assigned to Statistical Code WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 11 OF 48

12 II. WISCONSIN REPORTING REQUIREMENTS A. Rules Common to Premiums and Losses 1. Form of Report WCSTAT files, as found in the WCIO Data Specifications Manual, consist of data comprising Header, Name, Address (optional), Exposure, Loss, and Total records. Unit report data must be submitted electronically to WCRB. For further information regarding electronic reporting, please contact the WCRB or NCCI, Inc. Additional information can be found in section I. A. Scope of Report. Carriers who have never reported WCSTAT files electronically are required to test their electronic submissions with WCRB and receive approval prior to submitting their first electronic file of production data. WCSTAT Submission Instructions can be found on the WCRB Web site. 2. Estimated Audits If for any reason data is unavailable to the data provider before the filing date, an estimated audit must be filed with the Bureau and the Policy Condition Indicators- Estimated Audit Code shall be reported with the symbol "Y". A multiple correction report must be filed when final audited data becomes available. This report will update the header and exposure record detail. If a final audit cannot be obtained, the WCRB must be notified and the estimated audit will be used as the final audit. 3. Fraction of Dollars Report all monetary amounts in whole dollars only. 4. Method of Transmittal a. WCSTAT files shall be submitted on a monthly basis, except that the data provider may submit electronic files more frequently if the data provider so desires. b. WCSTAT files shall be transmitted to WCRB via CDX with an electronic letter of transmittal by a responsible official of the data provider. 5. Dates All dates shall be reported using a numeric designation, e.g. April 1, 2009 should appear as B. Header Data Elements and Definitions ASWG Unit Format Submission Code This code identifies a unit statistical report that is being reported in the ASWG format. All unit reports with effective dates 1/1/96 and later must be reported in the ASWG format. (Refer to section III. A.7 for list of ASWG Unit Format Submission Codes.) WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 12 OF 48

13 II. WISCONSIN REPORTING REQUIREMENTS (cont'd) BEEP Use Edit Bypass Code (Applicable to BEEP submissions only) BEEP (Bureau Entry & Edit Package) uses this field to indicate when a unit statistical report has been forced onto the submission file without passing all of the validations. (Refer to section III. A.6 for list of BEEP Use Edit Bypass Codes.) Only unit statistical reports in a Passed Status can be submitted to WCRB. For previously reported ( Update Type equal to P ), some data field edits will be bypassed. These edits are still processed as warnings, but do not cause a unit statistical report to fail validation. Carrier Code The code assigned to the reporting carrier by NCCI, Inc. Correction Sequence Number The sequential number that corresponds to the number of correction reports submitted within a particular report level. (Refer to section II. H. b. for conditions requiring a correction report.) Correction Type Code The code that indicates the type of correction report being submitted. Applicable only to correction reports. (Refer to section III. A.2 for the list of Correction Type Codes.) Exposure State Code The code that represents the state in which coverage has been provided. (Refer to section III. A.3 for the valid Exposure State Code.) Federal Employer ID Number (FEIN) The federal identification number 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. The Federal Employer Identification Number is optional. Policy Number Identifier The complete policy number must be reported AND MUST AGREE WITH THE 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. Policy Effective Date The effective date should correspond exactly with that shown on the policy information page or endorsements attached thereto. Policy Expiration or Cancellation 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. In the case of a multi-state policy, the policy expiration date shall be the expiration date shown on the policy information page or the date operations ceased in Wisconsin. Policy Conditions Indicators Indicators of various policy conditions. Indicate with a "Y" in the appropriate field for each condition that applies, and an N in the appropriate field for each condition code that does not apply. (Refer to section III. A.5 for list of Policy Conditions.) WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 13 OF 48

14 II. WISCONSIN REPORTING REQUIREMENTS (cont'd) Policy Type ID Codes Identifies the type of coverage, plan indicator and non-standard provisions of the policy. (Refer to section III. A. 4 for list of Policy Type ID Codes.) Previous Report Level Code/Report Number The report number code that was previously reported. Previous Correction Sequence Number The correction sequence number that was previously reported. Previous Carrier Code The carrier code that was previously reported. Previous Policy Number Identifier The policy number identifier that was previously reported. Previous Policy Effective Date The policy effective date that was previously reported. Previous Exposure State Code The exposure state code that was previously reported. Replacement Report Code For data providers electing to file data directly with WCRB, report an R to identify a Replacement Report being submitted in response to a unit report in a Rejected status in WCRB s Web product, Manage USR. Otherwise, leave this field blank. Carriers not reporting unit statistical data directly with WCRB must contact NCCI, Inc. for reporting procedures. Report Level Code/Report Number The code that corresponds to the valuation date. (Refer to section III. A.1 for list of report numbers and valuation dates.) 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 month of the policy. Subsequent Reports: Second reports are valued exactly 30 months from the policy effective month. Third reports are valued exactly 42 months from the policy effective month. Fourth reports are valued exactly 54 months from the policy effective month. Fifth reports are valued exactly 66 months from the policy effective month. Sixth reports are valued exactly 78 months from the policy effective month. Seventh reports are valued exactly 90 months from the policy effective month. Eighth reports are valued exactly 102 months from the policy effective month. Ninth reports are valued exactly 114 months from the policy effective month. Tenth reports are valued exactly 126 months from the policy effective month. WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 14 OF 48

15 II. WISCONSIN REPORTING REQUIREMENTS (cont d) Risk ID Number The identification number assigned to the risk by the bureau issuing the experience rating. The Risk ID Number is optional. State Effective Date The date coverage begins in Wisconsin on a multi-state policy where Wisconsin has been added mid-term. C. Name Record Data Elements and Definitions Insured Name 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. D. Address Record Data Elements and Definitions Insured Address The address 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. The Address of the Insured is optional. E. Exposure Record Data Elements and Definitions Classification Code The code corresponding to the insured's classification determined according to classification rules of the Bureau and published in the Basic Manual for Worker s Compensation and for Employers Liability Insurance. Experience Modification Effective Date Normally, this is the effective date of the policy. However, if the experience modification changes during the policy period, in accordance with Experience Rating Manual rules, this is the effective date of the experience modification that applies to the exposure reported in this detail record. If the anniversary rating date is different from the policy effective date, then the modification effective date equals the anniversary rating date. NOTE: The Experience Modification Effective Date for split 0 must always equal the policy effective date on the unit report s Header Record. The Experience Modification Effective Date is a required data element when reporting electronically. Policies effective September 1, 2013, the note above is no longer applicable. Experience Modification Factor The experience modification is used to develop charged premium, expressed as a decimal, (e.g.,.95 for 5% credit, 1.00 for a "neutral" modification, or 1.05 for a 5% debit) shall be reported on every classification for a risk that is subject to experience rating. If a change in the experience modification occurs subsequent to inception date of the policy, the Exposure Amounts, Manual/Charged Rates, and corresponding Premium Amount shall be split and reported with unique split dates. The period covered by each report shall be shown by appropriate notation in the Experience Modification Effective Date and/or Rate Effective Date fields NOTE: A "neutral" modification may not be used for a non-rated risk and must be reported as WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 15 OF 48

16 II. WISCONSIN REPORTING REQUIREMENTS (cont d) Exposure Act/Exposure Coverage Code The code indicating the Act (Law) under which the exposure for this record's Classification Code is associated. (Refer to section III. B.2 for list of Exposure Act/Exposure Coverage Codes.) Exposure Amount Exposure Amounts (payroll) reported is audited payrolls, even on minimum premium risks. Payrolls must be appropriately separated, as of the effective date of the changes whenever there is a change in experience modification. The total payroll for all classifications is to be reported in the Exposure Payroll Total field. The payroll exposures for non-ratable (supplemental and catastrophe loading) portions are not to be included in the Exposure Payroll Total field. 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 Bureau Rates provide coverage for silicosis) will have a special supplementary disease rate charge. Such payroll, together with the manual premium derived from the supplemental rate charge, shall be assigned to the appropriate Classification Code. Refer to section III. B. 3. Premium Codes of this Plan for a complete list. The payroll reported for these codes shall be reported but shall not be used in determining the risk's Exposure Payroll Total. However, the premium resulting from the application of the supplemental disease rates shall be included in the Standard Premium Total. 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. Such payroll, together with the Manual premium from the mandatory catastrophe reserve rate charge, shall be assigned to the appropriate Classification Code: Class Hazard Code 4771 Explosives or Ammunition Mfg NOC 0771 & Drivers 7405 Air Carrier Scheduled or Supplemental: 7445 Flying Crew 7431 Aircraft or Helicopter Operation: 7453 Air Carrier Commuter Flying Crew Reporting Instructions for Policies Where No Exposure Was Developed When a policy is issued on an if any basis, or as estimated coverage in Wisconsin, and upon audit no exposure developed, two methods of reporting the unit statistical data can be used: WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 16 OF 48

17 II. WISCONSIN REPORTING REQUIREMENTS (cont d) Method 1: Report the Classification Codes with zeros in the Exposure Amount and Premium Amount fields. Report the applicable rate for the Classification Code in the Manual/Charged Rate field. Report any other statistical codes that are policy related, such as the Expense Constant, Waiver of Subrogation, and Premium for Increased Liability codes, as identified on the policy. Method 2: Report statistical code 1111 with zeros in the Exposure Amount, Premium Amount, and Manual/Charged Rate fields. Report any other statistical codes that are policy related such as the Expense Constant, Waiver of Subrogation, and Premium for Increased Liability codes, as identified on the policy. No losses should be reported on unit statistical reports for policies where no exposure developed. Manual/Charged Rate The rates as approved for use in Wisconsin shall be shown against the classifications and Exposure Amounts to which they are applicable. Premium Amount Premium by Classification. The premium reported by Classification Code shall be that obtained by extension of the payroll or other exposure at the rates, and shall be reported in the field captioned Premium Amount. Where a classification includes a non-ratable element or supplemental loading, only the ratable portion of the premium should be reported with the policy s experience modification factor. The non-ratable portion is not reported with an experience modification factor. Miscellaneous Premium. The Bureau rules provide for additional premium charges for various special conditions or additional coverage, such as Aircraft Seat Surcharge, Excess Limits under Part II, etc. These additional premium charges are reported in the field captioned Premium Amount. (See E.1. of this section). The exposure items if any shall be reported in the field captioned Exposure Amount. NOTE: The passenger seat surcharge is not applicable for policies effective January 1, 2015 and subsequent. Rate Effective Date Normally, this is the effective date of the rate that corresponds to the classification code and exposure. However, if the rate changes during the policy period, in accordance with Basic Manual rules, this is the rate effective date that applies to the classification code and exposure reported in this detail record. NOTE: The Rate Effective Date for split 0 must always equal the policy effective date on the unit report s Header Record. The Rate Effective Date is a required data element when reporting electronically. For policies effective September 1, 2013, the note above is no longer applicable. Split Period Code This code is used to indicate change in manual/charged rates or modification factors during life of policy. For policies with no change in manual/charged rates or modification factors this field will be zero filled. For policies with changes in manual/charged rates or modification factors, report 0 for the first period, 1 for the second period, 2 for the third period, etc., through 9. Update Type Code The code that identifies the activity of an Exposure Record. (Refer to section III. B. 1 for list of Update Type Codes.) WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 17 OF 48

18 II. WISCONSIN REPORTING REQUIREMENTS (cont d) Miscellaneous Premium and Credits a. Premium Subject to Experience Modification Premium for Increased Limits under Part II of the policy to be reported in the aggregate in the Premium Amount field, assigned to the appropriate code. (Refer to section III. B. 3. for limits and percentages). The Basic Manual rules provide that the premium for limits shall be determined by applying the appropriate factors to the total premium, before any applicable experience modification. These codes should not be used in connection with the reporting of excess premium developed for higher limits on voluntary compensation policies. For such cases, the Basic Manual rules contemplate that the premium for coverage in excess of standard limits is provided by an appropriate increase in the Manual/Charged 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 data provider for such increased limits, the corresponding minimum premium shall be shown opposite the appropriate Statistical Code Per Capita Classifications. Experience on per capita classifications (Classification Codes 0908 and 0913) shall be reported in the Exposure Amount field by 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 10. 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 3. Exposure shall be governed by the duration of the coverage and not by the number of days worked. Exposure Amounts for these Classification Codes are not included in the Exposure Payroll Total Field. WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 18 OF 48

19 II. WISCONSIN REPORTING REQUIREMENTS (cont d) Volunteer Firemen Classification Code Where the policy provides coverage for Volunteer Firemen, report the total premium from the chart in Wisconsin rate pages. No Exposure Amount or Manual/Charged Rate should be reported. Work-Study Program Classification Code Report the total premium charge incurred when the policy provides coverage for students under this program. No Exposure Amount or Manual/Charged Rate should be reported. Additional Premium Resulting From Flat Increase on Outstanding Policies Statistical Code 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 manual rate basis and shall be assigned to Statistical Code 0998 and reported in the Premium Amount field. The Exposure Amount and Manual/Charged Rate fields shall be zero filled. Premium Credit Resulting From Flat Decrease on Outstanding Policies Statistical 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 manual rate basis and shall be assigned to Statistical Code 0994 and reported in the Premium Amount field. The Exposure Amount and Manual/Charged Rate field shall be zero filled. Additional premium for Admiralty or FELA coverage refer to section III. B.3. for limits and codes. Waiver of Subrogation Report the premium charged for the waiver of subrogation under Statistical Code NOTE: Statistical Code 0930 is applicable for policies with an effective date prior to October 26, Refer to Circular Letter 2885 December 7, Statistical Code 0930 is not applicable for policies effective October 1, 2006 through September 30, Statistical Code 0930 is applicable for policies effective October 1, 2008 and current. Refer to Circular Letter 3026 April 10, Statistical Code 0930 is applicable for policies effective July 12, 2013 and current. Refer to Circular Letter 3104 July 16, WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 19 OF 48

20 II. WISCONSIN REPORTING REQUIREMENTS (cont d) Short Rate Penalty Premium Statistical Code 0931 Where policies are canceled prior to normal expiration, the cancellation date shall be reported in the block captioned Policy Expiration Date and the symbol "Y" reported in the Policy Condition Field Canceled Mid-Term. When a policy is canceled short rate, the Exposure Amount and Manual premium by classification shall be reported on the basis of the actual exposure. The experience mod, 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 Statistical Code 0931 and reported in the Premium Amount field. The Exposure Amount and Manual Rate fields shall be zero filled. b. Premium Not Subject to Experience Modification Aircraft Operation Passenger Seat Surcharge. Passenger seat surcharge premiums shall be reported separately on the basis of each aircraft owned or operated by the risk during the policy period and shall be assigned to Statistical Code The number of seats shall be reported as 10 per seat. The Exposure Amount is not included in the Exposure Payroll Total Field. NOTE: The passenger seat surcharge is not applicable for policies effective January 1, 2015 and subsequent. Contractor s Premium Adjustment Credit Statistical Code Report the contracting credit modification factor in the rate field, and the amount of premium credit. Waiver of Subrogation Statistical Code Report the premium charged for the waiver of subrogation for policies with an effective date of October 26, 2001 and after. Statistical Code Report the premium charged for the waiver of subrogation for policies with an effective date of July 12, 2013 and after. Refer to Circular Letter 3104 July 16, Work-Study Program For policies effective and subsequent. Refer to Circular Letter 3097, January 3, Secondary Schools Classification Code Report the total premium charge incurred when the policy provides coverage for students under this program. No Exposure Amount or Manual/Charged Rate should be reported. Post Secondary Schools Classification Code Report the total premium charge incurred when the policy provides coverage for students under this program. No Exposure Amount or Manual/Charged Rate should be reported. See Basic Manual for instructions when applying Work Study Program Codes. Non-Ratable Statistical Codes. Refer to II. E. Exposure Amount of this section. Statistical Code 0771 Explosives or Ammunition Mfg NOC & Drivers Statistical Code 7445 Air Carrier Scheduled or Supplemental: Flying Crew Statistical Code 7453 Aircraft or Helicopter Operation: Air Carrier Commuter Flying Crew c. Non-Standard Premium Codes not included in the Total Standard Premium Premium Discount Statistical Code 0063 or If premium discount is applied, the total amount of the discount shall be assigned to Statistical Code 0063 WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 20 OF 48

21 II. WISCONSIN REPORTING REQUIREMENTS (cont d) Non-Standard Premium Codes not included in the Total Standard Premium (cont d) Terrorism Risk Insurance Act (TRIA) Statistical Code On each policy where a premium is charged for TRIA, the amount charged shall be assigned to Statistical Code Do not include the premium in the Standard Premium Total Amount. Code 9740 Catastrophe Provisions for Terrorism Not Part of Standard Premium (TRIPRA). Refer to Circular Letter 3031 July 22, Domestic Terrorism and Earthquake Coverage (DTEC) Statistical Code On each policy where a premium is charged for DTEC, the amount charged shall be assigned to Statistical Code Do not include the premium in the Total Standard Premium. Code 9741 Catastrophe Provisions for Catastrophe (other than Certified Acts of Terrorism). Refer to Circular Letter 3031 July 22, F. Loss Record Data Elements and Definitions Accident Date Report the month, day and year on which the injury occurred. In cases involving disease, the claim shall be assigned to the policy in force at the time the data provider became aware of the claim. In the event the data provider no longer insures the risk, the claim shall be assigned to the last policy issued by the data provider. The selected and indicated date of accident shall fall within the policy period, and not beyond the last full date of coverage. Catastrophe Number 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) resulting from this accident shall be designated by placing the numeral "01" in the field captioned Catastrophe Number. If there is more than one catastrophe under the policy, each succeeding catastrophe should be designated by means of a separate serial number "02", "03", etc. A separate series of catastrophe numbers shall be used for each policy. Catastrophe codes have been reserved for reporting all non-extraordinary Loss Event (ELE) catastrophes. Extraordinary Loss Event Catastrophe Numbers Catastrophe codes between 11 and 99 are assigned for each qualifying extraordinary loss event. This unique code provides the industry a standard for reporting associated losses and is used by the insurance industry to fulfill internal needs and bureau reporting purposes. The accident date range is based on each specific catastrophic event and is determined on a case-by-case basis. Claim Count Number of claims is reported as 1 for individually listed claims. Claim Number The number 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. WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 21 OF 48

22 II. WISCONSIN REPORTING REQUIREMENTS (cont'd) For policies effective and prior: At the option of the data provider, all other medical only claims may be listed individually or may be grouped by Manual classification and by type of injury within each Manual classification. The number of claims within each group shall be reported in the field captioned Claim Count. In counting the number of claims, claims closed without payment shall be omitted. If one or more claims within the group are open, such a group shall be considered open and revised experience shall be reported in accordance with the rules of this Plan. If the grouping option is elected, claims must be grouped separately according to loss conditions codes as designated in section III. C.4. For policies with an effective date prior to , it was permissible to group indemnity claims under $2,000 using the above criteria. For policies effective and after, the grouped claim reporting option is no longer a reporting option. All claims must be listed individually with the appropriate claim number. Claim/Status Code The code that indicates the status of the claim. (Refer to section III. C.3 for list of Claim/Status Codes.) Classification Code 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 Bureau. No claims may be assigned to any classification unless premium also has been reported for that class. Injury Code (Injury Type) The code that identifies under which provision of the law benefits are paid or expected to be paid. Death Cases Code 01 Report each death claim unless it has been established that the data provider has incurred no liability. The amount reported as indemnity incurred shall include all paid and outstanding benefits, including compensation paid to the deceased prior to death, burial expenses, and payments to the state. If there is compensation paid prior to the death of a claimant and there is later found to be no liability on the death claim, the loss is to be reported on the basis of the injury for which payments have previously been made. Permanent Total Disability Code 02 Report as permanent total each claim 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 data provider will result in permanent total disability. In general, permanent total disability includes cases involving the loss or loss of use of both hands, arms, feet, legs, eyes, or any combination of such members. Temporary Total or Temporary Partial Disability Code 05 Report 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 in this section. WI WORKERS COMPENSATION STATISTICAL PLAN MANUAL PAGE 22 OF 48