massachusetts workers' compensation statistical plan

MASSACHUSETTS

WORKERS’

COMPENSATION

STATISTICAL PLAN

The Workers’ Compensation Rating and

Inspection Bureau of Massachusetts

101 Arch Street, Boston, MA 02110

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

TABLE OF CONTENTS Page i

INTRODUCTION

PART I – UNIT STATISTICAL REPORTING

SECTION I - GENERAL INSTRUCTIONS

A. Unit Statistical Data

B. Validity of the Unit Statistical Report

C. Interstate Experience Rated Risks

D. Whole Dollar Reporting

E. Reinsurance

F. Uncollectible Premiums

G. Group Claim Option

H. Policy Term Greater Than One Year and 16 Days in Length

I. Special Rules for Reporting Disease Experience

J. Experience Under the National Defense Projects Rating Plan

K. Electronic Reporting

L. WCRIBMA Contact

SECTION II – FIRST UNIT STATISTICAL REPORTS AND RE-VALUATIONS

A. Date of Valuation and Filing

B. First Unit Statistical Reports

C. Re-Valuations (Subsequent Unit Statistical Reports)

D. Adjustment of Losses between Valuations

SECTION III – CORRECTIONS

A. Corrections Submitted between Valuations

B. Method of Reporting Corrections

C. Correction Type Code

D. Update Type Code

SECTION IV – HEADER INFORMATION

A. General Information

B. Header Information Data Element Index

C. Header Information Data Elements

1. Carrier Code

2. Policy Number Identifier

3. Exposure State Code

4. Policy Effective Date

5. Report Number

6. Correction Sequence Number

7. Policy Expiration or Cancellation Date

8. Replacement Report Code

9. Business Segment Identifier

10. Correction Type Code

11. State Effective Date

12. Federal Employer Identification Number (FEIN)

13. Three-Year Fixed Rate Policy Indicator

14. Multistate Policy Indicator

15. Interstate Rated Policy Indicator

16. Estimated Audit Code

17. Retrospective Rated Policy Indicator

18. Canceled Mid-Term Policy Indicator

19. Type of Coverage ID Code

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20. Type of Plan ID Code

21. Type of Non-Standard ID Code

22. Losses Subject to Deductible Code

23. Basis of Deductible Calculation Code

24. Deductible Amount Per Claim/Accident

25. Deductible Amount – Aggregate

26. Previous Report Number

27. Previous Correction Sequence Number

28. Previous Carrier Code

29. Previous Policy Number Identifier

30. Previous Policy Effective Date

31. Previous Exposure State Code

SECTION V - EXPOSURE RECORD DATA

A. General Information

B. Exposure Record Data Element Index

C. Exposure Record Data Elements

1. Classification Code (Class Code)

2. Experience Modification Factor (Experience Mod)

3. Experience Modification Effective Date (Mod Effective Date)

4. Rate Effective Date

5. Exposure Amount

6. Premium Amount

7. Manual Rate (WCRIBMA’s filed and approved rate)

8. Split Period Code

9. Update Type Code

10. Exposure Act/Exposure Coverage Code

SECTION VI - LOSS RECORD DATA

A. General Information

B. Loss Record Data Element Index

C. Loss Record Data Elements

1. Classification Code (Class Code)

2. Claim Count

3. Accident Date

4. Claim Number

5. Status Code

6. Injury Type Code

7. Catastrophe Number

8. Incurred Indemnity Amount

9. Incurred Medical Amount

10. Social Security Number

11. Update Type Code

12. Loss Coverage Act

13. Type of Loss

14. Type of Recovery

15. Type of Claim

16. Type of Settlement

17. Jurisdiction State Code

18. Part of Body

19. Nature of Injury

20. Cause of Injury

21. Occupation Description

22. Vocational Rehabilitation Indicator

23. Lump Sum Indicator

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24. Paid Indemnity Amount

25. Paid Medical Amount

26. Claimant’s Attorney Fees Incurred Amount

27. Employer’s Attorney Fees Incurred Amount

28. Paid Allocated Loss Adjustment Expense (ALAE) Amount

SECTION VII – ADDITIONAL REPORTING REQUIREMENTS ON DEATH AND PERMANENT TOTAL CLAIMS

A. Reporting Requirements

SECTION VIII - PENSION TABLES

A. Purpose

B. Non-USL&HW Pension Tables

C. USL&HW Pension Tables

PART II – AGGREGATE FINANCIAL REPORTING

SECTION I - GENERAL INSTRUCTIONS

A. Aggregate Financial Data

B. Cease Writing

C. Group Reporting

D. In Addition to Reports for NCCI or Other Rating Collection Organizations

E. Electronic Reporting

F. Whole Dollar Reporting

G. Reporting Credits

H. Direct Business

I. Policy Term Greater Than One Year and 16 Days in Length

J. M.G.L. Chapter 152 Section 65

K. WCRIBMA Contact

SECTION II – AGGREGATE FINANCIAL REPORTING TIMETABLE

A. Aggregate Financial Call Data Usage / Reporting Schedule

B. Timetable of Key Dates for Data Reporting

SECTION III – AGGREGATE FINANCIAL CALL ACKNOWLEDGMENT FORM

A. Description

B. General Instructions

C. Aggregate Financial Call Acknowledgment Form

SECTION IV – ANNUAL CALLS

POLICY YEAR CALLS – GENERAL INSTRUCTIONS

CALL # 2 – POLICY YEAR CALL

CALL #2A: POLICY YEAR RESIDUAL MARKET CALL

CALL #2C: POLICY YEAR LARGE DEDUCTIBLE CALL

CALL #2D: POLICY YEAR “F” CLASSIFICATION CALL

CALL #2E: POLICY YEAR MARITIME CLASSIFICATION CALL

ACCIDENT YEAR CALLS – GENERAL INSTRUCTIONS

CALL #3 – ACCIDENT YEAR CALL

CALL # 3A – ACCIDENT YEAR RESIDUAL MARKET CALL

CALL # 3C– ACCIDENT YEAR LARGE DEDUCTIBLE CALL

CALL #4: RECONCILIATION REPORT

CALL #5 RESIDUAL MARKET DIRECT WRITTEN PREMIUM

CALL #5A – LARGE DEDUCTIBLE COMPANY LEVEL WRITTEN PREMIUM

CALL #5B – DIRECT WRITTEN PREMIUM

CALL #6: MASSACHUSETTS CALENDAR YEAR EXPENSE DATA

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CALL #6A: INSURANCE EXPENSE EXHIBIT

CALL # 7: LARGE LOSS & CATASTROPHE CALL

PART III – DEFINITIONS

A. Premiums Reported in Statistical Plan

B. Losses and Loss Adjustment Expenses (LAE) Reported in Statistical Plan

C. Claim Categories

D. Expenses

E. Experience Types

F. Class Categories

PART IV – EXAMINATIONS AND RECONCILIATIONS

A. Unit Statistical Reports and Aggregate Financial Data Reconciliations

B. Routine Reviews by the WCRIBMA (Targeted AUP)

C. Routine Engagements by Independent Auditing Firms (Triennial AUP)

PART V - DATA QUALITY COMPLIANCE PROGRAMS

A. Overview

B. Unit Statistical Data Quality Incentive Program (USDQIP)

C. Aggregate Financial Call Acknowledgment Process

D. Aggregate Financial Data Quality Incentive Program (AFDQIP)

E. Examinations and Reconciliations

F. Disciplinary Fine

G. Reporting of Fines to the Massachusetts Division of Insurance

H. Appeal of Penalties Levied under the Data Quality Compliance Programs

PART VI - APPENDICES

APPENDIX I – EXTRAORDINARY LOSS EVENT TABLE

APPENDIX II – STATISTICAL CLASS CODES

APPENDIX III – PENSION TABLES

INTRODUCTION

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Introduction Page 1

INTRODUCTION

The Workers’ Compensation Rating and Inspection Bureau of Massachusetts (WCRIBMA) collects unit

statistical data and aggregate financial data to fulfill its role as the designated rating organization and

statistical agent for the Massachusetts Commissioner of Insurance.

The Massachusetts Commissioner of Insurance issued general instructions, known as the Massachusetts

Workers’ Compensation Statistical Plan (Statistical Plan), on January 2, 1929, for the preparation and

filing of experience with the WCRIBMA on all policies effective in Massachusetts on and after January 1,

1929.

On June 30, 2000 the Massachusetts Commissioner of Insurance ordered that effective immediately Part

I of the Statistical Plan shall relate to the unit statistical data and Part II shall relate to aggregate financial

data.

The Statistical Plan contains the following Parts:

Part I – Unit Statistical Data

• The instructions for the reporting of unit statistical data are contained in “Part I – Unit Statistical

Reporting”.

• Applicability:

o Every insurance company authorized to transact the business of workers’ compensation

insurance within the Commonwealth of Massachusetts shall file with the WCRIBMA complete unit

statistical information in accordance with the instructions contained herein, for:

o every policy with Massachusetts exposure and

o policies where Massachusetts was included on an “if any basis” and subsequently did not

develop Massachusetts exposure.

o If an insurance company is no longer authorized to transact the business of workers’

compensation in Massachusetts, it must continue the reporting of complete unit statistical

information in accordance with the instructions contained herein for all policies written.

o Self-Insurance Groups may contract with the WCRIBMA for purposes of calculating experience

ratings and consequently would have to adhere to the rules for reporting unit statistical data.

Part II – Aggregate Financial Data

• The instructions, and sample forms for the reporting of aggregate financial data are contained in “Part

II – Aggregate Financial Reporting”.

• Applicability:

o Every insurance company authorized to transact the business of workers’ compensation

insurance within the Commonwealth of Massachusetts shall file with the WCRIBMA complete

aggregate financial data in accordance with the instructions contained herein, on every policy.

o Insurance companies who cease writing workers’ compensation insurance may request to be

exempt from submitting aggregate financial data if their Massachusetts workers’ compensation

direct calendar year earned premium does not exceed $100,000 and their direct calendar year

incurred losses do not exceed $100,000.

o Self-Insurance Groups authorized to transact the business of workers’ compensation insurance

within the Commonwealth of Massachusetts are not required to file aggregate financial data with

the WCRIBMA.

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Part III – Definitions

• The definitions for terms associated with reporting unit statistical data and aggregate financial data

are included in “Part III – Definitions”.

Part IV– Examinations and Reconciliations

• Information detailing the reconciliation of unit statistical data and aggregate financial data is outlined

in “Part IV – Examinations and Reconciliations”.

Part V – Data Quality Compliance Programs

The WCRIBMA’s data quality fining processes for unit statistical data and aggregate financial data

are detailed in “Part V – Data Quality Compliance Programs”.

Circular letters announcing changes will be posted on the WCRIBMA’s website.

PART I

UNIT STATISTICAL REPORTING

SECTION I

GENERAL INSTRUCTIONS

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Part I – Unit Statistical Reporting Page 1

PART I – UNIT STATISTICAL REPORTING

SECTION I - GENERAL INSTRUCTIONS

A. Unit Statistical Data

1. Unit statistical data is the exposure, premium, and loss information that is first valued 18 months

after the policy effective date and annually thereafter.

2. WCRIBMA collects, processes, and analyzes unit statistical data for the following purposes:

• Ratemaking

• Experience rating

• Actuarial analysis

3. The classifications, exposure act and rates reported on unit statistical reports must be consistent

with the WCRIBMA’s filed and approved rates.

4. The premiums reported on unit statistical reports must be consistent with the WCRIBMA’s filed

and approved rating procedures.

5. Unit statistical reports should reflect exposures and premiums as of the final audit of the policy. If

the final audit has not been completed, report estimated exposures and premiums pending

completion of the audit.

6. All reported injuries that incurred medical loss, indemnity loss, or allocated loss adjustment

expense must be reported as claims consistent with the carrier’s claim files at the appropriate

valuation date.

B. Validity of the Unit Statistical Report

The unit statistical reports submitted to the WCRIBMA are edited for accuracy and validity including

but not limited to the following criteria:

1. The unit conforms to the rating rules found in the

Massachusetts Workers Compensation and

Employers Liability Insurance Manual, Experience Rating Plan Manual, Retrospective Rating

Plan Manual. Department of Insurance Regulations and Bulletins and other guides and manuals

distributed by or on behalf of the WCRIBMA. Nothing in the Statistical Plan should be construed

to supersede any rules or procedures set forth in the above mentioned manuals.

2. The unit reflects coverage and benefits in accordance with the Massachusetts Workers’

Compensation Law, Federal Employers’ Liability Act (FELA), Merchant Marine Act of 1920

(Jones Act) and United States Longshore and Harbor Workers’ Compensation Act including

Defense Base Act, Civilian Employees of Nonappropriated Fund Instrumentalities Act and Outer

Continental Shelf Lands Act.

3. The statistical class codes and other elements contained on the unit statistical report must

conform to this Statistical Plan.

C. Interstate Experience Rated Risks

For all interstate experience rated risks, a duplicate copy of the Massachusetts experience shall also

be filed with the National Council on Compensation Insurance (NCCI).

D. Whole Dollar Reporting

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All dollar amounts should be reported as whole numbers without decimal places. Values to the right

of any decimal place that are greater than or equal to .50 should be rounded upward. Values to the

right of the decimal place that are less than or equal to .49 should be rounded downward.

E. Reinsurance

No deduction is made from premiums and losses for, or as a result of, reinsurance ceded.

Premiums and losses associated with reinsurance assumed by the reporting carriers are excluded

from the experience reported to the WCRIBMA.

F. Uncollectible Premiums

1. For those policies on which an audit has been conducted and the earned premium is known, but

all or some portion thereof is uncollectible, report all earned premiums. Do not reduce reported

premiums for uncollectible premiums.

2. Policies on which a final audit is not possible and therefore the audited earned premium and

exposure is not known, report the estimated earned premium and exposure corresponding to the

term of coverage.

G. Group Claim Option

For policies effective on or after January 1, 2007, it is no longer permissible to group any claims for

unit statistical reporting purposes.

H. Policy Term Greater Than One Year and 16 Days in Length

If the policy term is a multiple of 12 months, the policy term is divided into consecutive 12 month

segments.

If the policy term is not a multiple of 12 months, the policy term is segmented in the same manner as

specified on the Policy Period Endorsement (WC000405). The Policy Period Endorsement identifies

either the first or last segment as the short-term segment, a segment of less than 12 months.

The beginning date for each segment shall be used for determining when losses are to be valued

and when unit statistical reports are due. This is comparable to the use of the policy effective date

for determining when losses are to be valued and when unit statistical reports are due for policies

having a term of no more than one year and 16 days.

Examples:

1. The unit statistical reports on a three-year policy effective on July 1, 2008 shall be filed with the

regular unit statistical reports on policies effective July 2008, July 2009, and July 2010. First unit

statistical report losses shall be valued as of January 1, 2010, January 1, 2011, and January 1,

2012, respectively.

2. The unit statistical reports on a policy covering the period July 1, 2008 to October 1, 2009 with

the first three months specified as the first reporting segment on the policy period endorsement,

shall be filed with the regular unit statistical reports on policies effective July 2008 and October

2008. First unit statistical report losses shall be valued as of January 1, 2010 and April 2010,

respectively.

3. The unit statistical reports on a policy covering the period July 1, 2008 to October 1, 2009 with

the first twelve months specified as the first reporting segment on the policy period endorsement

shall be filed with the regular unit statistical reports on policies effective July 2008, and July

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Part I – Unit Statistical Reporting Page 3

2009. First unit statistical report losses shall be valued as of January 1, 2010 and January 1,

2011, respectively.

Note: A policy issued for a term not longer than one year and 16 days is treated as a one-year

policy.

I. Special Rules for Reporting Disease Experience

1. Specific Disease Loading - Manual rates include premium for the disease exposures covered by

the Standard Policy. The rates for certain class codes contain specific disease loads which may

be removed if approved by the WCRIBMA. If the specific disease load is removed from the rate,

the reported rate should equal the WCRIBMA approved rate less the specific disease load.

Also, associated premiums should reflect the rate reduction resulting from the removal of the

specific disease load.

For more information refer to the

Massachusetts Workers Compensation and Employers Liability

Insurance Manual

2. Supplemental Disease Loading - A supplemental disease loading may be added to a manual

rate applicable to an individual risk if approved by the WCRIBMA. If a supplemental disease

load is added to a rate, the reported rate should equal the WCRIBMA approved rate plus the

supplemental disease load. Also, associated premiums should reflect the rate increase resulting

from the addition of the supplemental disease load.

For more information refer to the

Massachusetts Workers Compensation and Employers Liability

Insurance Manual.

3. Supplemental Disease Rates

Massachusetts Workers Compensation and Employers Liability

Insurance Manual rules provide that the payroll of all employees exposed to (a) a foundry hazard

(except payrolls properly assignable to certain specific codes) or (b) an abrasive or sand blasting

hazard (except for employees rated under a classification where the manual rate provides

coverage for silicosis) must be specifically stated and a special supplementary disease rate shall

be charged on this payroll in addition to the manual rate. The payroll to which the

supplementary disease rate is applicable, together with the manual premium derived from such

charges, shall be assigned to the appropriate statistical class code-either 0065, 0066, 0067, or

0059.

Dust disease losses incurred in connection with payrolls reported under statistical class code

0065, 0066, 0067 or 0059 shall likewise be assigned to the same statistical class code.

4. Disease losses shall be identified in the type of loss field by the appropriate code for disease

loss. Refer to Section VI – Loss Record Data, Subsection C.13

J. Experience Under the National Defense Projects Rating Plan

The experience of policies written under the National Defense Projects Rating Plan shall not be

reported on unit statistical reports.

K. Electronic Reporting

All unit statistical reports must be submitted electronically. The electronic data submission

requirements can be found in the Data Reporting area of the WCRIBMA’s web site

.

Data file formats are found in the

Workers Compensation Insurance Organizations (WCIO) Data

Specifications Manual.

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L. WCRIBMA Contact

All correspondence, including questions and requests for additional information on these calls,

should be directed to:

Data Operations Department – WCRIBMA

101 Arch Street, Fifth Floor

Boston, MA 02110

Phone: (617) 439-9030

Fax: (617) 439-6055

Email: DataOperations@wcribma.org

PART I

UNIT STATISTICAL REPORTING

SECTION II

FIRST UNIT STATISTICAL REPORTS

AND

RE-VALUATIONS

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SECTION II – FIRST UNIT STATISTICAL REPORTS AND RE-VALUATIONS

A. Date of Valuation and Filing

Unit statistical reports are valued and due as follows:

Unit

Statistical

Report

Level

Number of

months since

policy (or

segment)

effective

month

Due at

WCRIBMA

(in months)

Delinquent and

Fined on First

day of the

following month

Data Reported

Exposure Loss

First 18 20 21st X X

Second 30 32 33rd X

Third 42 44 45th X

Fourth 54 56 57th X

Fifth 66 68 69th X

Sixth 78 80 81st X

Seventh 90 92 93rd X

Eighth 102 104 105th X

Ninth 114 116 117th X

Tenth 126 128 129th X

B. First Unit Statistical Reports

1. The premium and losses of each policy are first valued as of eighteen (18) months after the

policy effective month and reported no later than twenty (20) months after the policy effective

month.

2. Update Type Code

• All exposure and loss records on first unit statistical reports must contain an update type

code as follows:

Code Description

R

Each record reported on first unit statistical reports must use code

“R” only.

C. Re-Valuations (Subsequent Unit Statistical Reports)

1. Subsequent unit statistical reports are re-valuations of losses and are required when:

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• The prior unit statistical report contained open claim(s).

• One or more claims reported as closed on the prior unit statistical report has since

reopened.

• Previously unreported claim(s) have become known.

• There are changes in the loss valuation of one or more claims.

2. Subsequent unit statistical reports of losses are reported in the same manner as loss

corrections as described in Section III - Corrections

.

3. Update Type Code

• All loss records on re-valuations must contain an update type code as follows:

Code Description

P

To delete a record from a previous unit statistical report use

update type code “P” only.

R

To add a data record that was not previously reported use update

type code “R” only.

P, R

To revise previously reported data:

• use update type “P” to delete the record

• use update type “R” to add a record with the revised data.

• For claims becoming non-compensable or closed without payment, or claims reflecting

received recovery, the “R” record must be reported so that information is coded in the

loss condition fields.

D. Adjustment of Losses between Valuations

Losses cannot be revised between two valuations because of departmental or judicial decision or

because of developments in the nature of the injury, except as listed in

Section III - Corrections,

Subsection A.

PART I

UNIT STATISTICAL REPORTING

SECTION III

CORRECTIONS

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Part I – Unit Statistical Reporting Page 1

SECTION III – CORRECTIONS

A. Corrections Submitted between Valuations

Corrections are to be submitted between valuations for only the following situations.

1. Errors (Header Records, Exposure Records and Loss Records)

An error occurs whenever the standards specified in

Section I – General Instructions,

Subsection B are not met.

Upon identification of an error by either the WCRIBMA or the carrier on a previously

submitted unit statistical report, a correction report must be immediately filed.

The WCRIBMA routinely requests verification of reported data. In response to these

verification requests the WCRIBMA expects corrections or acceptable explanations that

confirm the data as accurate and reported in accordance with the Statistical Plan.

For loss records, corrections must be submitted for all previous unit statistical report levels

(valuations) that contain the error.

2. Formerly Self-Insured’s Deposit Adjustments (Exposure Record)

If any of the formerly self-insured’s rating plan deposit is returned to the insured, then a

correction to the first unit statistical report must be submitted when the deposit is returned.

3. Completion or Change in the Audit (Exposure Record)

Corrections to the first unit statistical report must be submitted whenever an audit is revised,

or upon completion of the audit when the first unit statistical report was submitted based on

estimated exposure.

4. Non-Compensable Claims (Loss Record)

a. Non-Compensable Claims Definition

A claim is determined to be non-compensable if:

• There is an official ruling denying benefits under the Workers’ Compensation Law.

• A claimant fails to file for benefits during the period of limitation allowed by the

Workers’ Compensation Law.

• The claimant fails to prosecute his/her claim following carrier’s denial of the claim.

b. Non-Compensable Claims Reporting

If a claim is determined to be non-compensable prior to the first unit statistical report

valuation, do not report the claim. If a claim is determined to be non-compensable after

the first unit statistical report valuation, a correction report must be submitted within 60

days of such determination for all report levels (valuations) to revise the

Type of

Settlement Code to “05” (non-compensable). All report levels (valuations) whether at the

first unit statistical reporting or by correction should reflect accurate amounts paid by the

carrier net of recovery, if any.

5. Recovery from Second Injury Fund (Loss Record)

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a. Second Injury Fund Definition

The Second Injury Fund is established to reimburse the carriers when a subsequent

injury is caused by or made substantially greater due to the combined effects of physical

impairment, or previous accident, disease or congenital condition.

b. Second Injury Fund Reporting

Correction reports may be required for previously submitted unit statistical reports where

the previously reported incurred losses exceed the incurred loss net of a second injury

fund reimbursement and valued at the time of the second injury fund reimbursement.

When such a second injury fund reimbursement is received subsequent to the reporting

of the first unit statistical report but before the sixth unit statistical report’s due date, a

correction report must be filed.

When a second injury fund reimbursement is received on or after the sixth unit statistical

report’s due date, no correction report is required.

Note: If a claim is subject to second injury fund reimbursement prior to the submission of

the first unit statistical report, the loss amounts on the originally submitted first unit

statistical report should have been reported net of the second injury fund

reimbursement. Therefore, no correction would be needed.

If the allocation between incurred indemnity and incurred medical of the second injury

fund reimbursement is not specified, then the net incurred loss must be divided between

indemnity and medical in the same proportions as the gross incurred indemnity and

medical amounts. The net incurred loss would be calculated as follows:

Net Incurred Loss = Gross Incurred Loss – Second Injury Fund Reimbursement

Additionally, if a correction report is required and the previously reported paid losses

exceed the net paid loss valued at the time of the second injury fund reimbursement,

previously reported paid losses must be corrected. If the allocation between paid

indemnity and paid medical of the second injury fund reimbursement is not specified,

then the net paid loss must be divided between indemnity and medical in the same

proportions as the gross paid indemnity and medical amounts. The net paid loss would

be calculated as follows:

Net Paid Loss = Gross Paid Loss – Second Injury Fund Reimbursement

Note: The trigger for determining if a correction report is required is based on the incurred

loss and not the paid loss.

Corrections must be submitted within 60 days of the second injury fund reimbursement.

c. Second Injury Fund Example

Assumptions: The following is a reporting example where the carrier submitted a claim

on a first, second and third unit statistical report and second injury fund reimbursement

was received between the third and fourth unit statistical reports. The reported loss

amounts and the loss amounts valued at the time of the second injury fund

reimbursement are as follows:

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Incurred Losses Paid Losses

Valuation

Point

Gross

Indemnity

Gross

Medical

Reimbursement

Received

Net

Incurred

Loss

Gross

Indemnity

Gross

Medical

Reimbursement

Received

Net

Paid

Loss

1

st

Report 15,000 15,000

30,000 10,000 9,000

19,000

2

nd

Report 35,000 25,000

60,000 20,000 18,000

38,000

3

rd

Report 40,000 26,000

66,000 28,000 22,000

50,000

Date of SIF

Reimbursement

43,000 27,000

20,000

50,000 35,000 25,000

20,000

40,000

As of a date between the valuation date of the third unit statistical report and the

valuation date of the fourth unit statistical report, the carrier received a second injury fund

reimbursement in the amount of $20,000.

The allocation of the second injury fund reimbursement between indemnity and medical

was not specified.

Process: The carrier was required to perform the following steps to determine firstly if

correction reports were required for any report level, and, secondly the proper allocation

of the second injury fund reimbursement to indemnity loss and medical loss for both

incurred and paid amounts.

Step 1:

Determine if the second injury fund reimbursement is received on or after the 6th unit

statistical report’s due date. If not continue to Step 2. If so, no correction report is

required.

Step 2:

Determine which unit statistical reports are subject to correction by identifying those unit

statistical reports where the previously reported incurred losses exceed the net incurred

losses at the time of the second injury fund reimbursement.

Note: The determination of which unit statistical reports are subject to correction is based

only on incurred losses and not paid losses.

The incurred loss of $30,000 for the first report does not exceed the net incurred loss of

the claim at time of the second injury fund reimbursement which is equal to $50,000. No

correction report is needed.

The incurred loss of $60,000 for the second report does exceed the $50,000 net incurred

loss of the claim at time of the second injury fund reimbursement. A correction report is

needed.

The incurred loss of $66,000 for the third report does exceed the $50,000 net incurred

loss of the claim at time of the second injury fund reimbursement. A correction report is

needed.

Step 3:

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Revise the third unit statistical report – Incurred Losses

Allocate the net incurred loss of $50,000 based on gross incurred indemnity and incurred

medical at the time of recovery:

Corrected Incurred Indemnity: $50,000 x ($43,000 / $70,000) = $30,714

Corrected Incurred Medical: $50,000 x ($27,000 / $70,000) = $19,286

Step 4:

Revise the third unit statistical report – Paid Losses, if necessary

If the previously reported paid loss on the third unit statistical report exceeds the $40,000

net paid loss of the claim at time of the second injury fund reimbursement, the previously

reported paid loss amounts must be corrected.

In this case, the previously reported paid loss of $50,000 exceeds $40,000, the net paid

loss of the claim at time of the second injury fund reimbursement. Therefore, the

correction report must contain corrected paid loss amounts.

Allocate the net paid loss of $40,000 based on paid indemnity and paid medical at the

time of recovery:

Corrected Paid Indemnity: $40,000 x ($35,000 / $60,000) = $23,333

Corrected Paid Medical: $40,000 x ($25,000 / $60,000) = $16,667

Step 5:

Revise the second unit statistical report – Incurred Losses

As with the correction of the third report, allocate the net incurred loss of $50,000 based

on gross incurred indemnity and incurred medical at the time of recovery:

Corrected Incurred Indemnity: $50,000 x ($43,000 / $70,000) = $30,714

Corrected Incurred Medical: $50,000 x ($27,000 / $70,000) = $19,286

Step 6:

Revise the second unit statistical report – Paid Losses, if necessary

Since the previously reported paid loss on the second unit statistical report, $38,000,

does not exceed, $40,000, the net paid loss of the claim at time of the second injury fund

reimbursement, the previously reported paid loss amounts do not require correction.

Step 7:

Prepare the correction report to the second and third unit statistical reports to include the

necessary corrected loss amounts and also report the claim with Type of Recovery

Code

“02”.

Note: For a claim that was previously reported as closed which needs to be corrected

due to a second injury fund reimbursement, the corrected paid amounts should be equal

to the corrected incurred amounts.

6. Receipt of Successful Subrogation Recovery from a Third Party (other than from Second

Injury Fund) (Loss Record)

a. Successful Subrogation Recovery Reporting

Correction reports may be required for previously submitted unit statistical reports where

the previously reported incurred losses exceed the incurred loss net of a successful

subrogation

recovery and valued at the time of the subrogation recovery. When such a

successful subrogation recovery is received subsequent to the reporting of the first unit

statistical report but before the sixth unit statistical report’s due date, a correction report

must be filed.

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When a subrogation recovery is received on or after the sixth unit statistical report’s due

date, no correction report is required.

Note: If a claim is subject to subrogation recovery prior to the submission of the first unit

statistical report, the loss amounts on the originally submitted first unit statistical report

should have been reported net of subrogation. Therefore, no correction would be

needed.

Note: If the costs associated with pursuing subrogation recovery exceed the subrogation

recovery amount, no correction reports are required.

If the allocation between incurred indemnity and incurred medical of the subrogation

recovery less costs associated with pursuing the subrogation recovery is not specified,

then the net incurred loss must be divided between indemnity and medical in the same

proportions as the gross incurred indemnity and medical amounts. The net incurred loss

would be calculated as follows:

Net Incurred Loss = Gross Incurred Loss – (Subrogation – Recovery Expense)

Additionally, if a correction report is required and the previously reported paid losses

exceed the net paid loss valued at the time of the subrogation recovery, previously

reported paid losses must be corrected. If the allocation between paid indemnity and

paid medical of the subrogation recovery less costs associated with pursuing the

subrogation recovery is not specified, then the net paid loss must be divided between

indemnity and medical in the same proportions as the gross paid indemnity and medical

amounts. The net paid loss would be calculated as follows:

Net Paid Loss = Gross Paid Loss – (Subrogation – Recovery Expense)

Note: The trigger for determining if a correction report is required is based on the incurred

loss and not the paid loss.

Corrections must be submitted within 60 days of the subrogation recovery.

b. Subrogation Recovery Example

Assumptions: The following is a reporting example where the carrier submitted a claim

on a first, second and third unit statistical report and successful subrogation recovery was

received between the third and fourth unit statistical reports. The reported loss amounts

and the loss amounts valued at the time of the subrogation recovery are as follows:

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Incurred Losses Paid Losses

Valuation

Point

Gross

Indemnity

Gross

Medical

Subrogation

Recovery

Less

Recovery

Expenses

Net

Incurred

Loss

Gross

Indemnity

Gross

Medical

Subrogation

Recovery

Less

Recovery

Expenses

Net

Paid

Loss

1

st

Report 15,000 15,000

30,000 10,000 9,000

19,000

2

nd

Report 35,000 25,000

60,000 20,000 18,000

38,000

3

rd

Report 40,000 26,000

66,000 28,000 22,000

50,000

Date of

Subrogation

Recovery

43,000 27,000 15,000 55,000 35,000 25,000 15,000 45,000

As of a date between the valuation date of the third unit statistical report and the

valuation date of the fourth unit statistical report, the carrier received a subrogation

recovery in the amount of $20,000.

At the time when the carrier received the $20,000 subrogation recovery, the carrier had

spent $5,000 in legal expenses to pursue the subrogation.

The allocation of the subrogation recovery between indemnity and medical was not

specified.

Process: The carrier was required to perform the following steps to determine firstly if

correction reports were required for any report level, and, secondly the proper allocation

of the subrogation recovery to indemnity loss and medical loss for both incurred and paid

amounts.

Step 1:

Determine if subrogation was successful subrogation. In other words, did the

subrogation recovery exceed the costs associated with pursuing the subrogation?

If subrogation recovery exceeds the expenses associated with pursuing recovery

(recovery expenses), a correction report may be required. Move to Step 2.

If subrogation recovery does not exceed the expense associated with pursuing recovery,

no correction report is required. Stop here.

Step 2:

Determine if the subrogation recovery is received on or after the sixth unit statistical

report’s due date. If not continue to Step 3. If so, no correction report is required and

stop here.

Step 3:

Determine which unit statistical reports are subject to correction by identifying those unit

statistical reports where the previously reported incurred losses exceed the net incurred

losses at the time of the subrogation recovery. Net incurred loss should be calculated as:

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Net Incurred Loss = Gross Incurred Loss – (Subrogation – Recovery Expenses)

Note: The determination of which unit statistical reports are subject to correction is based

only on incurred losses and not paid losses.

The incurred loss of $30,000 for the first report does not exceed the net incurred loss of

the claim at time of the subrogation recovery which is equal to $55,000. No correction

report is needed.

The incurred loss of $60,000 for the second report does exceed the $55,000 net incurred

loss of the claim at time of the subrogation recovery. A correction report is needed.

The incurred loss of $66,000 for the third report does exceed the $55,000 net incurred

loss of the claim at time of the subrogation recovery. A correction report is needed.

Step 4:

Revise the third unit statistical report – Incurred Losses

Allocate the net incurred loss of $55,000 based on gross incurred indemnity and incurred

medical at the time of recovery:

Corrected Incurred Indemnity: $55,000 x ($43,000 / $70,000) = $33,876

Corrected Incurred Medical: $55,000 x ($27,000 / $70,000) = $21,214

Step 5:

Revise the third unit statistical report – Paid Losses, if necessary

If the previously reported paid loss on the third unit statistical report exceeds the $45,000

net paid loss of the claim at time of the subrogation recovery, the previously reported paid

loss amounts must be corrected. Net paid loss should be calculated as:

Net Paid Loss = Gross Paid Loss – (Subrogation – Recovery Expenses)

In this case, the previously reported paid loss of $50,000 exceeds $45,000, net paid loss

of the claim at time of the subrogation recovery. Therefore, the correction report must

contain corrected paid loss amounts.

Allocate the net paid loss of $45,000 based on paid indemnity and paid medical at the

time of recovery:

Corrected Paid Indemnity: $45,000 x ($35,000 / $60,000) = $26,250

Corrected Paid Medical: $45,000 x ($25,000 / $60,000) = $18,750

Step 6:

Revise the second unit statistical report – Incurred Losses

As with the correction of the third report, allocate the net incurred loss of $55,000 based

on gross incurred indemnity and incurred medical at the time of recovery:

Corrected Incurred Indemnity: $55,000 x ($43,000 / $70,000) = $33,876

Corrected Incurred Medical: $55,000 x ($27,000 / $70,000) = $21,214

Step 7:

Revise the second unit statistical report – Paid Losses, if necessary

Since the previously reported paid loss on the second unit statistical report, $38,000,

does not exceed the $45,000 net paid loss of the claim at time of the subrogation

recovery, the previously reported paid loss amounts do not require correction.

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Step 8:

Prepare the correction report to the second and third unit statistical reports to include the

necessary corrected loss amounts and also report the claim with Type of Recovery

Code

“03”.

Note: For a claim that was previously reported as closed which needs to be corrected

due to a subrogation recovery, the corrected paid amounts should be equal to the

corrected incurred amounts.

7. Aggravated Inequity (Loss Record)

An aggravated inequity is a claim that closes between the valuation date and the next rating

effective date for an amount less than the amount valued previously. The necessary

correction report is to be submitted upon the WCRIBMA’s request or once the carrier

determines that the difference between the previously reported incurred losses and the final

paid losses constitutes an aggravated inequity, whichever comes first. See the

Experience

Rating Plan Manual for more information.

8. Extraordinary Loss Event (Loss Record)

Corrections must be submitted for all unit statistical reports when it has been determined that

one or more claims should be reported with a catastrophe code identifying an extraordinary

loss event. (Refer to Section VI – Loss Record Data, Subsection C.7 for a definition of

Extraordinary Loss Event

Claims).

B. Method of Reporting Corrections

1. Correction reports

Correction reports can be used to change previously reported data and must be reported with

a sequence number greater than “0” for a given unit statistical report level. Refer to

Section

IV – Header Information, Subsection C.6.

2. Replacement reports

Replacement reports can be used to completely replace a previously submitted unit. Refer to

Section IV – Header Information, Subsection C.8

.

3. Deletions of Entire Units

Entire units (reports or correction reports) can be deleted only by sending a written request to

the Data Operations Department via email (DataOperation[email protected]

) or to the following

address:

Data Operations Department

WCRIBMA

101 Arch Street, 5th Floor

Boston, MA 02110

The reason for the request must be specified.

C. Correction Type Code

The correction type code identifies the type of correction report being submitted and is applicable

only to correction reports.

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Code Description

H

Header Record Correction:

• Link Data Elements

• Non-Link Data Elements

E

Exposure Record Correction (first unit statistical reports only)

L Loss Record Correction – Not an Aggravated Inequity

A

Loss Record Correction – Aggravated Inequity

This type of correction cannot be reported on a multiple record type.

M

Corrections to Multiple Record Types - Combinations of corrections

to header, exposure, or loss record. Aggravated inequity corrections

must be reported separately.

1. Header Corrections – Link Data Elements

Link data is the set of elements which uniquely identifies a unit.

a. The link data elements are:

• carrier code

• policy number identifier

• exposure state code

• policy effective date

• report number

• correction sequence number

b. For corrections to link elements use correction type code “H”. There are two separate and

distinct fields that should be used in the correction of each link element. For example,

there are both policy number and previous policy number fields. To correct a policy

number, the revised policy number is inserted in the policy number field, and the policy

number as it appeared on the prior unit(s) is inserted in the previous policy number field.

• A carrier cannot revise report number or correction sequence number. If a situation

arises that requires modification of these fields, contact the WCRIBMA Data

Operations department at DataOperations@wcribma.org

.

• Link data corrections are applied directly to each individual unit statistical report. If

three unit statistical reports (1st, 2nd, and 3rd) have already been submitted and an

error in the link data is discovered, then corrections for all three unit statistical reports

are necessary. A link data correction to only one of the previously filed unit statistical

reports will cause that corrected report to either match (link) with another policy and

set of unit reports, or to become “unmatched”.

If a correction report is submitted with link data that don’t match our records, then the

correction cannot be correctly applied to the WCRIBMA’s data base. Invalid carrier

code, policy number, policy effective date, report number or exposure state on a

correction report will cause the correction to be rejected or incorrectly applied to

previously submitted data. The carrier must replace or amend these correction

reports.

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2. Header Corrections – Non-Link Data Elements

a. The policy/header non-link data elements eligible for carrier update as header corrections

are:

• policy expiration date

• risk identification number

• replacement report code

• business segment identifier

• correction type code

• state effective date

• federal employer identification number

• three-year fixed rate policy indicator

• multistate policy indicator

• interstate rated policy indicator

• estimated audit code

• retrospective rated policy indicator

• canceled mid-term policy indicator

• type of coverage identification code

• type of plan identification code

• type of non-standard identification code

• losses subject to deductible code

• basis of deductible calculation code

• deductible amount per claim/accident

• deductible amount – aggregate

b. For corrections to all non-link header data elements use correction type code “H” or “M”.

c. Non-link data corrections are to be reported on corrections to first unit statistical reports

only.

D. Update Type Code

• All exposure and loss records on correction reports must contain update type code as

follows:

Code Description

P

To delete a record from a previous unit statistical

report use

update type code “P” only.

R

To add a data record that was not previously reported use update

type code “R” only.

P, R

To revise previously reported data:

• use update type “P” to delete the record

• use update type “R” to add a record with the revised data.

• For claims becoming non-compensable or closed without payment, or claims reflecting

received recovery, the “R” record must be reported so that information is coded in the loss

condition fields.

PART I

UNIT STATISTICAL REPORTING

SECTION IV

HEADER INFORMATION

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Part I – Unit Statistical Reporting Page 1

SECTION IV – HEADER INFORMATION

This section is organized into the following components:

• General Information

• Header Information Data Element Index

• Header Information Data Elements

A. General Information

The header information is data that are specific to the coverage of the policy. These elements

include the link data which connect all records to a unit and each unit to a policy.

B. Header Information Data Element Index

Header information requires the full reporting of all fields.

NO. DATA ELEMENT PAGE

23 Basis of Deductible Calculation Code 7

9 Business Segment Identifier 5

18 Canceled Mid-Term Policy Indicator 5

1 Carrier Code 2

6 Correction Sequence Number 3

10 Correction Type Code 5

25 Deductible Amount – Aggregate 7

24 Deductible Amount Per Claim/Accident 7

16 Estimated Audit Code 5

3 Exposure State Code 2

12 Federal Employer Identification Number 5

15 Interstate Rated Policy Indicator 5

22 Losses Subject to Deductible Code 6

14 Multistate Policy Indicator 5

4 Policy Effective Date 3

7 Policy Expiration or Cancellation Date 4

2 Policy Number Identifier 2

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NO. DATA ELEMENT PAGE

28 Previous Carrier Code 7

27 Previous Correction Sequence Number 7

31 Previous Exposure State 8

30 Previous Policy Effective Date 8

29 Previous Policy Number Identifier 8

26 Previous Report Number 7

8 Replacement Report Code 4

5 Report Number 3

17 Retrospective Rated Policy Indicator 5

11 State Effective Date 5

13 Three-Year Fixed Rate Policy Indicator 5

19 Type of Coverage ID Code 6

21 Type of Non-Standard ID Code 6

20 Type of Plan ID Code 6

C. Header Information Data Elements

1. Carrier Code

Report the code assigned to the reporting company by NCCI.

2. Policy Number Identifier

Report the code that uniquely identifies the policy under which experience occurred excluding

blanks, punctuation marks, and special characters. The policy number identifier should

include the complete policy number as set forth on the Policy Information Page plus any

applicable prefixes or suffixes and must remain the same throughout the life of the policy.

3. Exposure State Code

Report code “20” for Massachusetts. If anything other than “20” is reported, it will be rejected.

4. Policy Effective Date

a. Standard term policies (up to one year and 16 days):

Report the month, day and year upon which the policy became effective.

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b. Extended term policies (more than one year and 16 days and up to three years):

• If the policy term is a multiple of 12 months, segment the policy term into consecutive

12 month periods. For each segment, report the beginning date of the segment in the

policy effective date field.

• If the policy term is not a multiple of 12 months, segment the policy term in

accordance with the policy period endorsement. For each segment, report the

beginning date of the segment in the policy effective date field.

5. Report Number

Report the code that corresponds to the loss valuation month.

Code

Unit Statistical

Report Level

Number of months

since policy or

segment effective

month

1 First 18

2 Second 30

3 Third 42

4 Fourth 54

5 Fifth 66

6 Sixth 78

7 Seventh 90

8 Eighth 102

9 Ninth 114

A Tenth 126

6. Correction Sequence Number

Report the sequential number that corresponds to the number of correction reports submitted

for a particular unit statistical report level. Use “1” through “9”, then “A” through “Z” as

correction sequence numbers for a unit statistical report level.

Report “0” in correction sequence number if original unit statistical report level submission.

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Examples:

Unit Statistical

Report

Level

Correction Sequence

Number

Original 1

st

USR

1

0

Original 2

nd

USR

2

0

First Correction to 2

nd

USR

2

1

Second Correction to 2

nd

USR

2

Third Correction to 2

nd

USR

2

3

Original 3

rd

USR

3

0

-

First Correction to 9

th

USR

9

1

Second Correction to 9

th

USR

9

2

-

Ninth Correction to 10

th

USR

A

9

Tenth Correction to 10

th

USR

A

7. Policy Expiration or Cancellation Date

a. Standard term policies (up to one year and 16 days):

• Non-cancelled policies

Report the month, day and year upon which the policy expired.

• Cancelled policies

Report the cancellation date as the expiration date.

b. Extended term policies (more than one year and 16 days and up to three years):

• Non-cancelled policies

o If the policy period is a multiple of 12 months, segment the policy into

consecutive 12 month periods. For each segment, report the ending date of the

segment in the policy expiration or cancellation date field.

o If the policy period is not a multiple of 12 months, segment the policy period in

accordance with the policy period endorsement. For each segment, report the

ending date of the segment in the policy expiration or cancellation date field.

• Cancelled policies

o Report the cancellation date as the expiration date of the segment in which the

cancellation is effective.

Note: For cancelled policies, the policy segment during which the cancellation is

effective is the last segment for which unit data should be reported. For example,

if a three year policy is cancelled during the second segment, unit data is only to

be reported for the first and second segments.

c. For a multi-state policy with Massachusetts exposure(s), the mid-term deletion of

Massachusetts is considered to be a Massachusetts cancellation and is reported as such

on Massachusetts unit statistical reports.

8. Replacement Report Code

When replacing a previously submitted unit statistical report enter code “R” in the

replacement report code field. For all unit statistical reports other than replacements this field

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should be blank. Submission of a replacement will delete previously reported unit statistical

reports from the WCRIBMA’s data base. Replacements can be submitted for unit statistical

reports which are accepted, rejected or failed. A replacement unit statistical report can be

used instead of a correction report.

9. Business Segment Identifier

Carriers, at their option, may report a business segment identification number.

For additional

information refer to Circular Letter 2159

.

10. Correction Type Code

Report the code that indicates the type of correction report being submitted. See

Section III –

Corrections, Subsection C for a list of correction type codes.

11. State Effective Date

Report the endorsement effective date if the Massachusetts coverage was endorsed mid-

term, otherwise zero-fill the field.

12. Federal Employer Identification Number (FEIN)

Report the Federal employer identification number of the insured as shown on the Policy

Information Page. If the policy has been endorsed to change the FEIN, report the FEIN from

the latest endorsement.

13. Three-Year Fixed Rate Policy Indicator

Y = Policy is a three-year fixed rate policy.

N = Policy is not a three-year fixed rate policy.

14. Multistate Policy Indicator

Y = If more than one state is listed in Item 3A of the Policy Information Page.

N = If only Massachusetts is listed in Item 3A of the Policy Information Page.

15. Interstate Rated Policy Indicator

Y = Policy is interstate rated in accordance with the Experience Rating Plan Manual

.

N = Policy is not interstate rated.

16. Estimated Audit Code

Y = Policy has estimated exposure(s).

N = Policy does not have estimated exposure(s).

U = Uncooperative. The insured has not cooperated with the carrier for purposes of auditing

exposure(s).

17. Retrospective Rated Policy Indicator

Y = Policy is retrospectively rated as defined in the Retrospective Rating Plan Manual

.

N = Policy is not retrospectively rated.

18. Canceled Mid-Term Policy Indicator

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Y = Policy term has been shortened by a cancellation and not subsequently reinstated.

For extended term policies, report “Y” only for the policy segment in which the

cancellation is effective.

N = Policy is full term and policy has not been canceled, or if the policy was canceled, it was

reinstated on the cancellation date.

19. Type of Coverage ID Code

Report the code that indicates the type of coverage.

Code Description

01

Standard Workers Compensation Policy other than “05” &

“09”

05

Large Risked Rate

d Option / Large Risk Alternative Rating

Option

09

Non-Standard Workers Compensation coverage (used only

in conjunction with other than code “01” in the Non-standard

Type ID Code)

20. Type of Plan ID Code

Report the code that indicates the type of plan.

Code Description

01 Voluntary Policy

02 Normal Assigned Risk Policy

05

Assigned Risk Policy written under Massachusetts Voluntary

Direct Assigned Risk Program

21. Type of Non-Standard ID Code

Report the code that indicates the type of workers compensation policy.

Code Description

01

Standard Workers Compensation

99 Self-Insured Groups

22. Losses Subject to Deductible Code

Report the code that identifies the type of losses subject to the deductible.

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Code Description

00 No Deductible

01

Medical – Deductible applies to the medical portion of the

loss only.

02

Indemnity –

Deductible applies to the indemnity portion of

the loss only.

03

Medical & Indemnity –

Deductible applies to the total of

medical and indemnity portions of the loss.

23. Basis of Deductible Calculation Code

Report the code that identifies the type of deductible being reported.

Code Description

00 No Deductible

01

Per Claim –

The deductible amount applies to each claim

arising from the policy and there is no aggregate deductible.

09

Per Accident and Policy (Aggregate) – The deductible amount

applies to each accident up to an aggregate limit and there is

no per claim deductible.

10

Per Claim and Policy (Aggregate) –

The deductible amount

applies to each claim up to an aggregated limit and there is no

per accident deductible.

12 Variable – Carrier program not described above.

24. Deductible Amount Per Claim/Accident

Report the maximum loss amount by claim or accident to be paid by the insured, if

applicable, as defined by the deductible program.

25. 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.

26. Previous Report Number

Not applicable to Massachusetts. If a unit statistical report has been accepted with the wrong

report number, contact the WCRIBMA to arrange for the deletion of the incorrect unit

statistical report and the replacement with a proper report number.

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27. Previous Correction Sequence Number

Not applicable to Massachusetts. If a unit statistical report has been accepted with the wrong

correction sequence number, contact the WCRIBMA to arrange for the deletion of the

incorrect unit and replacement with proper correction sequence number.

28. Previous Carrier Code

• This field only applies to correction reports.

• In the previous carrier code field, report the incorrect carrier code that was previously

submitted.

• In the carrier code field, report the correct carrier code.

29. Previous Policy Number Identifier

• This field only applies to correction reports.

• In the previous policy number identifier, report the incorrect policy number identifier that

was previously submitted.

• In the policy number identifier field, report the correct policy number identifier.

30. Previous Policy Effective Date

• This field only applies to correction reports.

• In the previous policy effective date, report the incorrect policy effective date that was

previously submitted.

• In the policy effective date, report the correct policy effective date.

31. Previous Exposure State Code

• This field only applies to correction reports.

• In the previous exposure state code, report the exposure state code “20”.

• In the exposure state code field, report a non-Massachusetts code.

• The result will be that the unit is dropped from the WCRIBMA’s data base.

PART I

UNIT STATISTICAL REPORTING

SECTION V

EXPOSURE RECORD DATA

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SECTION V - EXPOSURE RECORD DATA

This section is organized into the following components:

• General Information

• Exposure Record Data Element Index

• Exposure Record Data Elements

A. General Information

• The exposure record data elements are used to report the class, coverage, exposure, manual

rate, and premiums.

• For most first unit statistical reports, the experience modification effective date and rate

effective date will not change during the policy term. When multiple modification effective

dates or rate effective dates apply during a policy term, this may cause split periods. When

this occurs, the full policy term’s exposure and manual premiums must be split for each

period reflecting a change in the experience modification effective date and/or rate effective

date.

• For split policy periods, the prorated exposure and prorated premiums for the first split (split

period code “0”) correspond to the first period, and the prorated exposure and prorated

premiums for the second split (split period code “1”) correspond to the second period. Any

additional split periods are treated in the same manner.

B. Exposure Record Data Element Index

NO. DATA ELEMENT PAGE

1 Classification Code 2

3 Experience Modification Effective Date 2

2 Experience Modification Factor 2

5 Exposure Amount 2

10 Exposure Act/Exposure Coverage Code 4

7 Manual Rate 3

6 Premium Amount 3

4 Rate Effective Date 2

8 Split Period Code 3

9 Update Type Code 4

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Part I – Unit Statistical Reporting Page 2

C. Exposure Record Data Elements

1. Classification Code (Class Code)

Report the code(s) corresponding to the classification(s) assigned to the insured according to

the Massachusetts Workers Compensation and Employers Liability Insurance Manual

or the

statistical class codes defined in Appendix II – Statistical Class Codes. If no exposure

develops on a policy, use statistical class code 1111.

For any classification code, there cannot be more than one exposure record per unit with the

same manual rate, experience modification, rate effective date, exposure coverage code and

experience modification effective date.

2. Experience Modification Factor (Experience Mod)

For exposure(s) that are subject to application of an experience modification, report the

experience modification factor used to develop the premium.

For exposure(s) not subject to experience rating, report “0000”.

3. Experience Modification Effective Date (Mod Effective Date)

For exposure(s) subject to experience rating, report the date on which the experience mod is

applicable.

The Massachusetts Workers Compensation and Employers Liability Insurance Manual

rules

relating to anniversary rating dates may require that a policy’s exposure(s) be divided into

split periods. If this occurs, it is necessary to indicate the date on which the experience rating

is applicable for each split period.

The Experience Rating Plan Manual

contains rules that restrict the retroactive application of

an experience mod which consequently result in a policy’s exposure(s) being divided into split

periods. If this occurs, it is necessary to indicate the date on which the experience mod is

applicable for each split period.

Additionally midterm changes in coverage can create the need for split periods. An example

of this would be a midterm change to employer’s liability limits. For a split period being

reported due to a midterm change in coverage, report the date on which such change in

coverage is effective.

Note: For the first split period, a date prior to the policy effective date may be reported if the

anniversary rating date is prior to the policy effective date.

4. Rate Effective Date

Report the effective date of the WCRIBMA rate revision that is applicable to the exposure

record. This date can be prior to the policy effective date.

5. Exposure Amount

Report the exposure amount that is applicable to the exposure records as follow:

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: January 1, 2015 Section V

Distributed: December, 2014 EXPOSURE RECORD DATA

Part I – Unit Statistical Reporting Page 3

a. No-Exposure Developed

• If a policy does not develop any Massachusetts exposure, report zero for the

exposure amount on the exposure record containing statistical class code 1111 in the

class code field.

b. Payroll Exposure

• Report the payroll amount. Do not divide the payroll by 100.

• Report exposures for supplemental disease loads (statistical class codes 0059, 0065,

0066, 0067, 0133, 0179)

Note: The statistical class codes 0133 and 0179 were discontinued effective as of

January 1, 2008.

• Report exposures for Non-Ratable Elements (statistical class codes 0771, 7445,

7453).

c. Non-Payroll Exposure

• Per Capita Classifications(statistical class codes 0908, 0909, 0912 and 0913):

Report the number of employees covered, based on the duration of coverage. An

employee covered under a per capita class code for a period of one year must be

reported as an exposure of 1.0. If an employee is covered for a period other than one

year, the reported exposure should be calculated by dividing the number of days of

coverage by 365, and rounding the result to the nearest tenth of a year. For example,

if an employee is covered for 130 days, the exposure amount will be equal to 0.4

(=130/365 rounded to the nearest tenth).

6. Premium Amount

Report the premium amount corresponding to each classification.

• No-Exposure Developed

Premium Amount = $0

• Payroll Exposure

Premium Amount = (Exposure Amount ÷ 100) x WCRIBMA’s filed and approved rate

• Non-Payroll Exposure

Premium Amount = Exposure Amount x WCRIBMA’s filed and approved rate

• Other Premiums

This premium shall be reported under the appropriate statistical class code. Refer to the

Massachusetts Premium Algorithm

.

7. Manual Rate (WCRIBMA’s filed and approved rate)

For each classification report the WCRIBMA’s filed and approved rate. Do not report the

carrier’s specific rate that may reflect deviations.

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STATISTICAL PLAN

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Part I – Unit Statistical Reporting Page 4

8. Split Period Code

Report the code used to indicate changes in manual rates or rating factors during policy

period. For policies with no change in manual rates or rating factors, enter "0". For policies

with changes in manual rates or rating factors, refer to the following table:

Split

Period

Split

Period Code

1

st

0

2

nd

1

3

rd

2

4

th

3

5

th

4

6

th

5

7

th

6

8

th

7

9. Update Type Code

Report the code that identifies the type of update.

Code

Description

P Previously Reported Record

R Revised Record

• Both update type codes require the full reporting of all fields.

• For additional information refer to

Section II – First Unit Statistical Report and Re-

Valuations, Subsection B.2, Section II – First Unit Statistical Report and Re-Valuations,

Subsection C.3, Section III – Corrections, Subsection D.

10. Exposure Act/Exposure Coverage Code

Code

Description

00 For use with Statistical Class Codes*

01 State Act or Federal Act Excluding USL&HW

02

USL&HW “F” Classes or USL&HW coverage on Non “F” Classes

* Note: An exposure act/exposure coverage code is required for all exposure records.

Statistical class codes can be coded as “00”, or the act (law) governing the policy.

PART I

UNIT STATISTICAL REPORTING

SECTION VI

LOSS RECORD DATA

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section VI

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Part I – Unit Statistical Reporting Page 1

SECTION VI - LOSS RECORD DATA

Section VI of the Unit Statistical Reporting is organized into the following components:

• General Information

• Loss Record Data Element Index

• Loss Record Data Elements

A. General Information

The loss records contain the information specific to the benefit (claim) paid or case reserved for

injuries covered by the policy.

B. Loss Record Data Element Index

NO. DATA ELEMENT PAGE

3

Accident Date

2

7

Catastrophe Number

3

20

Cause of Injury Code

8

2

Claim Count

2

4

Claim Number

2

26

Claimant’s Attorney Fees Incurred Amount

8

1

Classification Code

2

27

Employer’s Attorney Fees Incurred Amount

8

Incurred Indemnity Amount

3

9

Incurred Medical Amount

4

6

Injury Type Code

3

17

Jurisdiction State Code

7

12

Loss Coverage Act Code

4

23

Lump Sum Indicator

8

19

Nature of Injury Code

7

21

Occupation Description

8

28

Paid Allocated Loss Adjustment Expense (ALAE) Amount

8

24

Paid Indemnity Amount

8

25

Paid Medical Amount

8

18

Part of Body Code

7

10

Social Security Number

4

5

Status Code

2

15

Type of Claim Code

6

13

Type of Loss Code

5

14

Type of Recovery Code

5

16

Type of Settlement Code

7

11

Update Type Code

4

22

Vocational Rehabilitation Indicator

8

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Part I – Unit Statistical Reporting Page 2

C. Loss Record Data Elements

1. Classification Code (Class Code)

Report the class code where the payroll or other exposure of the injured worker was reported.

2. Claim Count

a. Single Claim

Report the single claim as a number one (1).

b. Grouped Claims

Report the number of claims within each group as a number greater than one (1).

For policies effective on or after January 1, 2007, it is no longer permissible to group any

claims for reporting of unit statistical losses. Consequently, for all policies effective on or after

January 1, 2007 the claim count must be one (1).

3. Accident Date

The accident date of a claim can range from the policy effective date to the last full day of

coverage. Given that policies expire at 12:01 AM on the expiration date, the last possible full

day of coverage on a policy is the day prior to the policy expiration date. Claims that occur on

the expiration date of one policy and the effective date of renewal must be reported on the

renewal policy. The manner in which the accident date is reported is a function of the type as

loss as follows:

a. Trauma

Report the date on which the injury occurred.

b. Cumulative Injury - Occupational Disease

The accident date is either the last full day that the injured employee was covered within

the policy segment or the date that the injury was reported, whichever occurred first.

c. Cumulative Injury - Other Than Occupational Disease

The accident date is either the last full day that the injured employee was covered within

the policy segment or the date that the injury was reported, whichever occurred first.

4. Claim Number

A unique number assigned by the insurance company to a claim for the life of that claim.

Report the code that uniquely identifies the claim and represents one injured worker for both

medical and indemnity benefits. Exclude blanks, punctuation marks, and special characters.

Claim numbers must be reported in a manner consistent with aggregate financial reporting,

the Detailed Claim Information (DCI) reporting, and Medical Data Call reporting.

5. Status Code

Report the code that indicates the status of the claim.

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Part I – Unit Statistical Reporting Page 3

Code

Description

0 Open (future payments are expected to be made)

1 Closed (no future payments are expected to be made)

6. Injury Type Code

Report the code that identifies under which provision of the law benefits are paid or expected

to be paid.

Code Description

01

Death

A death claim is defined as

each claim where the injured worker has

died, unless it has bee

n established that the carrier has incurred no

liability.

02

Permanent Total Disability

A permanent total claim is defined as:

• Any claim which has been adjudged to constitute permanent total

disability.

• Any claim which is defined as such under the law, or which, in the

judgment of the carrier will result in permanent total disability.

05

Temporary Total Disability

A temporary total claim is defined as each claim

which involves or is

expected to involve indemnity benefits but which does not constitute a

case of death, permanent total or permanent partial.

06

Medical Claims Only

A medical claims only is defined as:

• Any

claim where there are only medical payments and there are

no indemnity losses.

• Any claim where there is no indemnity and no medical, but where

there is paid ALAE.

09

Permanent Partial Disability

A permanent partial claim is defined as:

•

Any permanent injury which does not involve permanent total

disability.

•

Any claim where the extent of future payments is indeterminate in

the judgment of

the carrier. The amount entered as indemnity

incurred shall include scheduled benefits and compensation for

temporary total disability as well as loss of future earning capacity.

7. Catastrophe Number

There are two types of claim events that are identified by the Catastrophe Number: Non-

Extraordinary Loss Event catastrophe claims and Extraordinary Loss Event catastrophe

claims.

MASSACHUSETTS WORKERS’ COMPENSATION

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Part I – Unit Statistical Reporting Page 4

• Non-Extraordinary Loss Event Claims (Catastrophe Numbers “01” – “10”)

A Non-Extraordinary Loss Event catastrophe is defined as any accident (one occurrence)

resulting in two or more reported claims on a policy for exposure within Massachusetts. If

there is more than one catastrophe under the policy, each succeeding catastrophe

number must be increased by one.

After the number “10” is assigned the next number in

the sequence will begin with number “01” again.

• Extraordinary Loss Event Claims (Catastrophe Numbers “11” – “99”)

An Extraordinary Loss Event (ELE) is a significant loss event which has been assigned a

catastrophe number by Insurance Services Office/Property Claim Services (ISO/PCS).

For those claims associated with the ELE’s listed in

Appendix I – Extraordinary Loss

Event Table, report the catastrophe number listed in the appendix.

8. Incurred Indemnity Amount

Report the amount of incurred indemnity losses as of the valuation date. Refer to Part III –

Definitions for the definition of incurred indemnity losses

.

9. Incurred Medical Amount

Report the amount of incurred medical losses, as of the valuation date. Refer to Part III –

Definitions for the definition of incurred medical losses

.

10. Social Security Number

Zero-filled. The social security number is no longer required or captured by any jurisdiction.

11. Update Type Code

Report the code that identifies the type of update.

Code

Description

P Previously Reported Record

R Revised Record

• Both update type codes require the full reporting of all fields.

• For additional information refer to

Section II – First Unit Statistical Report and Re-

Valuations, Subsection B.2, Section II – First Unit Statistical Report and Re-Valuations,

Subsection C.3, Section III – Corrections, Subsection D.

12. Loss Coverage Act Code

Report the code that corresponds to the loss coverage act.

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STATISTICAL PLAN

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Part I – Unit Statistical Reporting Page 5

Code Description

01

State Act or Federal Act Excluding USL&HW

A claim for which benefits are determined in accordance with the

Massachusetts Workers’ Compensation Law

, Federal Employers’

Liability Act (FELA) and Merchant Marine Act of 1920 (Jones Act).

02

USL&HW “F” Classes or USL&HW Non “F” Classes

A claim for which benefits are determined in accordance with the

United States Longshore and Harbor Workers’ Compensation Act,

Defense Base Act, Civilian Employees of Nonappropriated Fund

Instrumentalities Act and Outer Continental Shelf Lands Act.

13. Type of Loss Code

Report the code that corresponds to the type of loss.

Code Description

01

Trauma

•

An injury resulting in disability or death that is traceable to a single

identifiable incident occurring during the employ

ee’s (present or

past) employment.

02

Cumulative Injury: Occupational Disease

• An injury that results in a disability or death and is not traceable to a

single identifiable incident occurring during the employee’s (present

or past) employment.

• Any injury caused by repetitive exposure extending over time to a

disease producing agent or agents present in the worker’s

occupational environment.

• In order for a claim to be coded as an occupational disease case, it

must have resulted from repetitive exposure e

xtending over time.

Claims that arise from single identifiable incidents should be coded

as Trauma even though they may have been caused by inhalation,

absorption, ingestion, or other environmental factors.

• For example, a granite worker presents a claim for the occupational

disease of silicosis due to exposure to the disease agent silica.

03

Cumulative Injury: Other Than Occupational Disease

• An injury that results in a disability or death and is not traceable to a

single identifiable incident occurring during the employee’s (present

or past) employment.

•

The injury is understood to have occurred from, and has been

aggravated by, a repetitive employment related activity.

• For example, a cement mason or carpet or tile installer presents a

claim for injury to

the knee caused by repetitive bending and

kneeling on the job.

14. Type of Recovery Code

Report the code that corresponds to the type of recovery.

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STATISTICAL PLAN

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Part I – Unit Statistical Reporting Page 6

Code Description

01

No Recovery

Insurer has not received any recovery reimbursement.

02

Second Injury Fund Only

Carrier has received reimbursements from the Second Injury Fund.

03

Subrogation Only (Third Party)

Carrier has received reimbursement from an entity, other than the

employer, with legal liability due to circumstances of the injury.

04

Subrogation (Third Party) with Second Injury Fund

Carrier has received reimbursement from both the Second Injury

Fund and a Third Party.

15. Type of Claim Code

Report the code that corresponds to the type of claim.

Code Description

01

Workers Compensation Only

The entire loss is incurred under provisions of only Part One of the

Workers’ Compensation and Employer’s Liability Insurance Policy.

02

Employers Liability Only

The entire loss is incurred under provisions of only Part Two of the

Workers’ Compensation and Employer’s Liability Insurance Policy

including liability over claims.

03

Workers Compensation Including Employers Liability

The loss is incurred under provisions of both Part One and Part Two

of the Workers’ Compensation and Employer’s Liability Insurance

Policy including liability over claims.

16. Type of Settlement Code

Report the code that corresponds to the type of settlement.

Code Description

00

No settlement

No settlement applicable to the claim.

05

Non-Compensable

Claim has been determined to be non-

compensable as defined in

Section III – Corrections, Subsection A.4.

09

All Other Settlements

Claims not classified as “00” or “05”.

17. Jurisdiction State Code

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

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Distributed: August, 2013 LOSS RECORD DATA

Part I – Unit Statistical Reporting Page 7

Report the code of the governing jurisdiction that will administer the claim and whose statutes

will apply to the claim adjustment process when that jurisdiction state code is different from

the exposure state code.

For example: A Massachusetts school teacher is injured while attending a seminar in New

York. She may elect to pursue workers’ compensation benefits in Massachusetts or New

York. Assume she elects to pursue New York workers’ compensation benefits. In this

situation, her payroll is included on the unit statistical report for exposure state

Massachusetts and the loss record for her injury is reported on the unit statistical report with

exposure state Massachusetts. However, the jurisdiction state on the loss record for her

injury is New York because the workers’ compensation benefits were provided in accordance

with the workers’ compensation laws of the state of New York.

18. Part of Body Code

Report the code that represents the part of body to which the injury occurred.

Refer to the Workers Compensation Insurance Organizations (WCIO)

for a complete list of

part of body codes.

19. Nature of Injury Code

Report the code that represents the nature of injury sustained by the claimant.

Refer to the Workers Compensation Insurance Organizations (WCIO)

for a complete list of

nature of injury codes.

20. Cause of Injury Code

Report the code that represents the cause of injury.

Refer to the Workers Compensation Insurance Organizations (WCIO)

for a complete list of

cause of injury codes.

21. Occupation Description

Report a narrative description of the regular occupation of the injured worker.

Optional reporting for Massachusetts.

22. Vocational Rehabilitation Indicator

Report the value that indicates the inclusion of vocational rehabilitation costs in the losses.

Y = Claim includes vocational rehabilitation costs.

N = Claim does not include vocational rehabilitation costs.

23. Lump Sum Indicator

Report the value that identifies a lump sum agreement for the claim.

Y = A lump sum payment has been made.

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Part I – Unit Statistical Reporting Page 8

N = A lump sum payment has not been made.

24. Paid Indemnity Amount

Report the amount of paid indemnity losses as of the valuation date. Refer to Part III –

Definitions for the definition of paid indemnity losses

.

25. Paid Medical Amount

Report the amount of paid medical losses as of the valuation date. Refer to Part III –

Definitions for the definition of paid medical losses

.

26. Claimant’s Attorney Fees Incurred Amount

Report the amount paid plus outstanding case reserves as of the loss valuation date.

27. Employer’s Attorney Fees Incurred Amount

Report the amount paid plus outstanding case reserves as of the valuation date.

28. Paid Allocated Loss Adjustment Expense (ALAE) Amount

Report the amount of allocated loss adjustment expense. Refer to Part III – Definitions for the

definition of ALAE

.

PART I

UNIT STATISTICAL REPORTING

SECTION VII

ADDITIONAL REPORTING

REQUIREMENTS FOR DEATH AND

PERMANENT TOTAL CLAIMS

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section VII

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DEATH AND PERMANENT TOTAL CLAIMS

Part I – Unit Statistical Reporting Page 1

SECTION VII – ADDITIONAL REPORTING REQUIREMENTS ON DEATH AND PERMANENT TOTAL

CLAIMS

A. Reporting Requirements

1. The requirements under this section must be satisfied by participation in the

NCCI’s Detailed

Claim Information Program (DCI).

2. Every company shall maintain, store, and be prepared to report at least the following

information for every death claim and every permanent and total disability claim:

a. Identifying information listed below must match to the unit statistical report of the claim

and is defined and coded as specified in the previous sections of this Statistical Plan.

• Accident Date

• Carrier Code

• Claim Number

• Classification Code

• Policy Effective Date

• Policy Number

• Report Number

• Status Code

• Jurisdiction State Code

• Type of Loss Code

• Type of Recovery Code

• Type of Claim Code

• Part of Body Code

• Nature of Injury Code

• Cause of Injury Code

b. The additional claim information listed below is defined and coded as specified in the

NCCI’s Detailed Claim Information Reporting Guidebook

.

• Accident State Code

• Attorney or Authorized Representative Indicator

• Benefit Type Code

• Benefit Amounts Paid

o Death

o Permanent Total

o Scheduled Permanent Partial

o Unscheduled Permanent Partial

o Temporary Total

o Temporary Partial

o Employer’s Liability

o Disfigurement

o Supplemental

• Birth Year

• Claim Closing Date

• Claimant Gender Code

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

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DEATH AND PERMANENT TOTAL CLAIMS

Part I – Unit Statistical Reporting Page 2

• Controverted/Disputed Case Indicator

• Hire Year

• Impairment Percentage Basis Code

• Impairment/Disability Percentage

• Lump Sum Benefits Paid

o Death

o Permanent Total

o Scheduled Permanent Partial

o Unscheduled Permanent Partial

o Temporary Total

o Temporary Partial

o Employer’s Liability

o Disfigurement

o Supplemental

• Maximum Medical Improvement Date

• Medical Extinguishment Indicator

• Average Weekly Wage

o Post-Injury Average Weekly Wage

o Pre-Injury Average Weekly Wage

• Reported to Insurer Date

• Return to Work Date

• Return to Work Rate of Pay Indicator

• Vocational Rehabilitation

o Education Expense Amount Paid

o Evaluation Expense Amount Paid

o Maintenance Expense Amount Paid

o Other Amount Paid

• Method of Determining Preinjury/Average Weekly Wage Code

• Incurred Indemnity Amount Total

• Incurred Medical Amount Total

• Paid Medical Amount Total

• Maximum Medical Improvement Date

• Attorney or Authorized Representative Indicator

• Claimant Legal Amount Paid

• Employer Legal Amount Paid

• Extraordinary Loss Event Claim Indicator

• Recovery Reimbursement Amount

PART I

UNIT STATISTICAL REPORTING

SECTION VIII

PENSION TABLES

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section VIII

Distributed: August, 2013 Pension Tables

Part I – Unit Statistical Reporting Page 1

SECTION VIII - PENSION TABLES

A. Purpose

The reporting of incurred indemnity amounts for pension payments associated with fatal and

permanent total injuries should reflect a case reserve based on the annuity values contained in

Appendix III – Pension Tables

. The annuity values are an estimate of the present value of an

annual indemnity benefit which begins with a value of one dollar but is subject to applicable cost

of living adjustments (escalation). The duration of the pension payments is a function of the

beneficiary type - injured worker, surviving spouse, or dependents other than the surviving

spouse.

For a permanent total claim, pension benefits are paid to the injured worker until death. For a

death claim, a surviving spouse is entitled to benefits until death or remarriage and dependents

other than a surviving spouse are entitled to benefits until death or they are fully self-supporting.

The statute presumes that a child is self-supporting upon reaching the age of eighteen unless

they are physically or mentally incapacitated from earning or over said age and a full time student

qualified for exemption as a dependent under Section 151(e) of the Internal Revenue Code.

To be consistent with unit statistical reporting, the pension tables display annuity values for up to

ten years from the age as of date of the accident.

B. Non-USL&HW Pension Tables

The pension tables reflect the applicable provisions of the Massachusetts Workers’

Compensation Law, life expectancies derived from life tables published by the Centers for

Disease Control, and remarriage probabilities. In the case of permanent total claimants, the

tables also vary by the gender of the injured worker.

1. An escalation provision consistent with the current law is reflected in the derivation of all the

tables. The escalation rate is based on changes in the statewide average weekly wage and

CPI data. Additionally, losses are discounted for the time value of money. Annual discount

rate and annual escalation rate appear on each of the pension tables in

Appendix III –

Pension Tables.

2. Table Descriptions:

• Table IE-398

: Surviving Spouse - Fatal Claims

Utilizes female life expectancies and reflects the probability of remarriage.

• Table IIE-398

: Other than Surviving Spouse - Fatal Claims

Utilizes total population life expectancies.

• Table IIIEM-398 – Male

: Permanent Total Claimants

Utilizes male life expectancies and reflects a social security offset. The purpose of the

offset is to recognize that claimants are ineligible to receive workers’ compensation cost-

of-living adjustments that reduce their social security disability payments.

• Table IIIEF-398 – Female

: Permanent Total Claimants

Utilizes female life expectancies and reflects a social security offset. The purpose of the

offset is to recognize that claimants are ineligible to receive workers’ compensation cost-

of-living adjustments that reduce their social security disability payments.

MASSACHUSETTS WORKERS’ COMPENSATION

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Part I – Unit Statistical Reporting Page 2

C. USL&HW Pension Tables

1. These tables are used to estimate the present value of pension related indemnity benefits for

death and permanent total injuries payable in accordance with the United States Longshore

and Harbor Workers’ Act (USL&HW Act). The values contained in the pension tables are to

be used to calculate estimated case reserves for indemnity benefits for death and permanent

total injuries for purposes of reporting unit statistical reports to the WCRIBMA.

2. Table Descriptions:

• Table UI-USLH – Surviving Spouse

Apply this table for all death claims incurred under the USL&HW Act to estimate the

present value of the surviving spouse’s benefits, exclusive of any remarriage dowry. This

table is derived using female life expectancies and reflects the probability that the

surviving spouse remarries.

• Table UII-USLH – Present Value of Remarriage Dowry

Apply this table to all death claims incurred under the USL&HW Act to estimate the

present value of the surviving spouse’s remarriage dowry. This table is derived using

female life expectancies.

• Table UIIIM-USLH – Male Other than Surviving Spouse

Apply this table to all permanent total claims incurred under the USL&HW Act to estimate

the present value of wage losses benefits payable for the balance of a male claimant’s

life. This table is derived using male life expectancies.

• Table UIIIF-USLH – Female Other than Surviving Spouse

Apply this table to all permanent total claims incurred under the USL&HW Act to estimate

the present value of wage losses benefits payable for the balance of a female claimant’s

life. This table is derived using female life expectancies.

• Table UIV-USLH – Present Value of Survivorship Benefits

Apply this table to all permanent total claims incurred under the USL&HW Act to estimate

the present value of survivorship benefits. Note this table applies to surviving spouses of

a permanent total disability claimant. This table is derived using female life expectancies

and reflects the probability that the surviving spouse remarries.

This table should also be used to estimate the present value of survivorship benefits

related to death claims which are payable to someone other than a spouse.

3. Application of the tables

• Death Claims with a Surviving Spouse

Estimate the present value of survivorship benefits, excluding the remarriage dowry, by

using Table UI-USLH

(Surviving Spouse). Additionally, estimate the present value of the

remarriage dowry using Table UII-USLH (Present Value of Remarriage Dowry).

• Death Claims without a Surviving Spouse

Estimate the present value of survivorship benefits by using Table UIV-USLH

(Present

Value of Survivorship Benefits).

• Permanent Total Disability of a Male Claimant

Estimate the present value of wage loss benefits payable for the balance of a male

claimant’s life by using Table UIIIM-USLH

(Male Other than Surviving Spouse).

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section VIII

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Part I – Unit Statistical Reporting Page 3

Additionally, upon the death of the employee, survivorship benefits are payable to a

survivor and these should be estimated using Table UIV-USLH

(Present Value of

Survivorship Benefits).

• Permanent Total Disability of a Female Claimant

Estimate the present value of wage loss benefits payable for the balance of a female

claimant’s life by using Table UIIIF-USLH

(Female Other than Surviving Spouse).

Additionally, upon the death of the employee, survivorship benefits are payable to a

survivor and these should be estimated using

Table UIV-USLH (Present Value of

Survivorship Benefits).

PART II

AGGREGATE FINANCIAL REPORTING

SECTION I

GENERAL INSTRUCTIONS

MASSACHUSETTS WORKERS’ COMPENSATION

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Part II – Aggregate Financial Reporting Page 1

PART II – AGGREGATE FINANCIAL REPORTING

SECTION I - GENERAL INSTRUCTIONS

A. Aggregate Financial Data

1. WCRIBMA collects, processes, and analyzes aggregate financial data for the following

purposes:

• Ratemaking

• Actuarial analysis

• Data review / reconciliations

• Assigned Risk Pool participation ratios

• WCRIBMA Assessments

2. Calendar Year Data

Some calls require the reporting of calendar year data. Calendar year data are the sum of

changes in accounting balances for a particular year.

3. Accumulated Aggregate Data

Calls requesting policy year or accident year data require the reporting of accumulated

aggregate data, also referred to as inception to date.

In the case of premiums, submit the summation of all premiums and any subsequent

adjustments to premiums since the inception of each policy.

In the case of paid losses, submit the summation of all loss payments less recoveries since

the first unit statistical report of the claim.

4. Current Plus Twenty

The policy year and accident year calls require current plus twenty years of reporting. Data

related to years before the current plus twenty is combined and reported on the prior line.

For example, given a policy year data call valued as of 12/31/2003 for a company that has

workers’ compensation experience dating back to 1975, the policy years would be labeled as

follows:

Current Policy Year 2003

Plus Twenty Policy Years 1983 – 2002

Prior Policy Years Summation of 1975 – 1982

Similarly, the same company’s accident year call valued as of 12/31/2003 would classify the

accident years as follows:

Current Accident Year 2003

Plus Twenty Accident Years 1983 – 2002

Prior Accident Years Summation of 1975 – 1982

5. Aggregate financial instructions and general forms are provided in Part II of the Statistical

Plan.

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Part II – Aggregate Financial Reporting Page 2

B. Cease Writing

Insurance companies who cease writing workers’ compensation insurance may request to be

exempt from submitting aggregate financial data if their Massachusetts workers’ compensation

direct calendar year earned premium does not exceed $100,000 and their direct calendar year

incurred losses do not exceed $100,000. A letter requesting exemption must be remitted by the

carrier to the WCRIBMA at least 10 days prior to the first call due date. Within 5 days of receipt

of both the exemption request and the company annual statement, the WCRIBMA will respond

with a letter either accepting or denying the exemption.

If an insurance company that was previously granted exemption from reporting decides to write

again in the future, they must resume submitting aggregate financial data regardless of the size of

direct calendar year earned premium and direct calendar year incurred losses. However they will

have to choose whether or not they will report the historical data that was reported prior to the

exemption.

C. Group Reporting

The data for companies controlling, controlled by, or under common control with other companies

may be aggregated for purposes of reporting the data requested in Part II of the Statistical Plan.

Grouping of companies should remain consistent across time. If a change in corporate structure

results in a needed modification to the grouping of companies for the purpose of submitting

aggregate financial data, a request must be made to the WCRIBMA detailing the circumstances

of the transaction before September 1

st

for use of the new grouping of companies in the following

year.

Any companies electing group reporting must specify all companies to be grouped on the

financial Call Package Acknowledgement Form. Refer to

Subsection E – Electronic Reporting.

D. In Addition to Reports for NCCI or Other Rating Collection Organizations

The requirements of Part II of the Massachusetts Statistical Plan are independent of any

comparable requirements by any other rating collection organizations, including NCCI (National

Council on Compensation Insurance).

E. Electronic Reporting

1. All calls are to be submitted via the internet using the Massachusetts Financial Data Reporting

Application (MAFDRA) accessible at www.mafdra.org

. Please contact the WCRIBMA if a user

ID needs to be established for your company. Likewise, if a user ID currently exists for your

company and you have forgotten either the user ID or the password please contact the

WCRIBMA.

More specifics about electronic submission and the MAFDRA application can be found in the

MAFDRA User Guide. The MAFDRA User Guide may be accessed within the MAFDRA

application.

2. Nil Reports

When completing the Call Package Acknowledgment Form contained in MAFDRA,

companies with no experience to report for a particular call should inform the WCRIBMA by

unchecking the box next to the call in Section III of the form. MAFDRA will automatically

create these calls and insert zeros in all of the fields.

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Part II – Aggregate Financial Reporting Page 3

3. Data Provider Contact

Companies are required to complete two Acknowledgment Forms:

a. Call Package Acknowledgment Form

• This acknowledgment form requires that a contact be identified for each call except

those involving nil submissions.

• Any questions the WCRIBMA has relating to a given call will initially be directed to the

contact associated with that call. If initial WCRIBMA questions go without sufficient

response, the WCRIBMA will contact the primary contact listed on the Call Package

Acknowledgment Form or the carrier’s management.

• This acknowledgment form has to be completed online in MAFDRA.

b. Aggregate Financial Call Acknowledgment Form

• This acknowledgment form identifies a corporate officer or actuary who acknowledges

that, to the best of their knowledge, certain of the aggregate financial calls have been

completed accurately. The specific calls at issue are listed on the Aggregate Financial

Call Acknowledgment Form. Refer to

Section III – Aggregate Financial Call

Acknowledgment Form.

• A copy of this acknowledgment form has to be downloaded, completed and uploaded

in MAFDRA.

4. Changes to Contacts

Companies are required to inform the WCRIBMA of any changes to contacts by updating the

Call Package Acknowledgment Form. It is very important that contact information associated

with staff no longer working with a company or staff no longer responsible for reporting financial

data for a company is modified immediately. This action will help to ensure that important

WCRIBMA correspondence is delivered to the correct person. See the Financial Data Call

Package Acknowledgment Form section of the MAFDRA User’s Guide for instructions on

modifying contacts.

F. Whole Dollar Reporting

All dollar amounts should be reported as whole numbers without decimal places. Values to the

right of any decimal place that are greater than or equal to .50 should be rounded upward.

Values to the right of the decimal place that are less than or equal to .49 are to be rounded

downward.

G. Reporting Credits

Negative amounts should be reported using the negative sign. Do not report negative amounts

inside parenthesis. For example:

-1,000 Correct

(1,000) Incorrect

H. Direct Business

These calls require the reporting of direct business only. Do not report reinsurance assumed or

make adjustments for business that has been reinsured.

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Part II – Aggregate Financial Reporting Page 4

I. Policy Term Greater Than One Year and 16 Days in Length

Policies with terms greater than one year and 16 days that are effective on or after January 1,

2009 must be segmented for aggregate financial reporting purposes.

If the policy term is a multiple of 12 months, the policy term is divided into consecutive 12 month

segments. If the policy term is not a multiple of 12 months, the policy term is segmented in the

same manner as specified on the Policy Period Endorsement (WC000405). The Policy Period

Endorsement identifies either the first or last segment as the short-term segment, a segment of

less than 12 months.

The beginning date for each segment shall be used for determining the policy year. This is

comparable to the use of the policy effective date for determining the policy year for policies

having a term of no more than one year and 16 days.

J. M.G.L. Chapter 152 Section 65

1. DIA Assessment

The DIA assessment is not to be considered premium and should not be included in premium

totals.

2. Funds Maintained by the Treasurer of the Commonwealth of Massachusetts

Losses are reported net of second injury fund reimbursements from the Massachusetts

Workers' Compensation Trust Fund.

3. Penalties

a. Sections 7, 8, 10, 13A, and 14 of Chapter 152 provide for penalties or fees to be paid by

the insurer in specified situations.

Section 7 sets forth penalties in cases in which the insurer fails either to pay or deny a

claim promptly after receiving either a claim form or a First Report of Injury.

Section 8 sets forth penalties (i) in cases in which the insurer fails to make prompt

payments in accordance with an order, decision or agreement; and (ii) in cases in which

the insurer unlawfully terminates, reduces, or fails to make required payments and is later

ordered to do so.

Section 10 requires a penalty fee for referral to the Industrial Accident Board of 130% of the

average weekly wage in cases in which the insurer failed to appear at a scheduled

conciliation without good cause.

Section 13A (iii) provides for attorneys' fees to be paid to claimants in instances in which

insurers have been found to owe late payment penalties under Section 7 or 8 (described

above).

Section 14 provides for certain penalties where an Administrative Judge finds that the

insurer has brought, prosecuted or defended a proceeding without reasonable grounds.

b. Any amounts paid as penalties or fees in accordance with these provisions of law must not

be added to the losses reported on the data calls.

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Part II – Aggregate Financial Reporting Page 5

K. WCRIBMA Contact

All correspondence, including questions and requests for additional information on these calls,

should be directed to:

Data Operations Department – WCRIBMA

101 Arch Street, Fifth Floor

Boston, MA 02110

Phone: (617) 439-9030

Fax: (617) 439-6055

Email:

DataOperations@wcribma.org

PART II

AGGREGATE FINANCIAL REPORTING

SECTION II

AGGREGATE FINANCIAL REPORTING

TIMETABLE

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Part II – Aggregate Financial Reporting Page 1

SECTION II – AGGREGATE FINANCIAL REPORTING TIMETABLE

A. Aggregate Financial Call Data Usage / Reporting Schedule

Call

Number

Call Name

Purpose for

Collecting Data

Due Date

2 Policy Year Call Ratemaking March 15

2A Policy Year Residual Market Call Ratemaking March 15

2C Policy Year Large Deductible Call

Ratemaking and

Pool Participation

Ratios

March 15

2D Policy Year “F” Classification Call

Analysis of

Ratemaking Data

March 15

2E Policy Year Maritime Call Ratemaking March 15

3 Accident Year Call Ratemaking April 1

3A Accident Year Residual Market Call

Analysis of

Ratemaking Data

April 1

3C Accident Year Large Deductible Call

Analysis of

Ratemaking Data

April 1

4 Reconciliation Report

Data Review /

Reconciliation

April 1

5 Residual Market Direct Written Premium

Pool Participation

Ratios

April 1

5A

Large Deductible Written Calendar Year

Experience

Pool Participation

Ratios

April 1

5B Net Direct Written Premium

Assessments and

Pool Participation

Ratios

April 1

6 MA Calendar Year Expense Data Ratemaking May 15

6A Insurance Expense Exhibit

Analysis of

Ratemaking Data

April 15

7 Large Loss and Catastrophe Call Ratemaking April 15

Notes:

• Call Package Acknowledgment Form is to be completed by the end of February.

• Aggregate Financial Call Acknowledgment Form (See

Section III – Aggregate Financial

Call Acknowledgment Form, page 2) is to be completed by June 1.

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B. Timetable of Key Dates for Data Reporting

March 15 to June 30:

The WCRIBMA receives and reviews the most recent data submitted by each of the carrier

groups, runs the edits, and works with carrier groups to obtain any needed corrections or

explanations.

June 30:

The WCRIBMA notifies carrier groups of any observed data anomalies.

The WCRIBMA provides the Massachusetts Division of Insurance (DOI) with all carrier groups’

reported data and will continue to provide the DOI with carrier group reported data, as it may be

revised, on a monthly basis through November 30.

July 31:

Insurance groups with market shares exceeding a given threshold are subject to a Triennial

Agreed Upon Procedures (Triennial AUP). The carrier groups’ independent auditing firms submit

to the DOI and the WCRIBMA the Triennial AUP findings reports pursuant to

Part IV –

Examinations and Reconciliations, Subsection B.

June 30 to August 31:

The WCRIBMA continues to work with each of the carrier groups to resolve any observed data

anomalies.

August 31:

The WCRIBMA reports to the DOI the results of the Commissioner’s mandated reconciliations

which includes identifying all carrier groups with uncorrected or unexplained tolerance variances.

At the DOI’s request, any carrier group with such unexplained variances or other unresolved

issues may be required to have an independent auditing firm conduct an Targeted Agreed Upon

Procedures (Targeted AUP) of the carrier group’s data reporting activities.

September 1 to October 31:

On-site Targeted AUPs are conducted by independent auditing firms and the independent

auditing firms submit their findings reports to the DOI, the WCRIBMA and the carrier groups.

Carrier groups submit to the DOI and the WCRIBMA their responses to the independent auditing

firms’ findings reports no later than thirty (30) days following the carrier groups’ receipt of the

results of such findings report.

PART II

AGGREGATE FINANCIAL REPORTING

SECTION III

AGGREGATE FINANCIAL CALL

ACKNOWLEDGMENT FORM

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Part II – Aggregate Financial Reporting Page 1

SECTION III – AGGREGATE FINANCIAL CALL ACKNOWLEDGMENT FORM

A. Description

This form is required from all companies reporting aggregate financial data to the WCRIBMA,

including companies submitting all “NIL” reports. The Aggregate Financial Call Acknowledgment

Form must be completed and signed by a designated contact that will be responsible for verifying,

to the best of his/her knowledge and belief, the completeness and accurate representation of the

following calls:

Call Number

Call Name Due Date

2, 2A, 2C, 2D, 2E Policy Year Calls March 15

3, 3A, 3C Accident Year Calls April 1

4 Reconciliation Report April 1

5

Residual Market Direct Written

Premium Call

April 1

5A

Large Deductible Company Level

Written Premium

April 1

5B Direct Written Premium Call April 1

6 MA Calendar Year Expense Data May 15

6A Insurance Expense Exhibit April 15

7 Large Loss and Catastrophe Call April 15

B. General Instructions

• The acknowledgment must be signed by a company officer or a company actuary who is a

member of the Casualty Actuarial Society and/or a member in good standing of the American

Academy of Actuaries.

• If companies are grouped for purposes of aggregate financial data reporting, the Aggregate

Financial Call Acknowledgment Form would apply to the data for all companies assigned to the

group. An acknowledgement contact may sign for multiple reporting companies within their

carrier group if the calls were reported individually.

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C. Aggregate Financial Call Acknowledgment Form

Please provide the contact information for the company officer or company actuary responsible for

completion of this form. A non-officer actuarial designee must be a member of the Casualty

Actuarial Society and/or a member in good standing of the American Academy of Actuaries.

Acknowledgment Contact Information

Carrier Group Code

Carrier Group Name

Contact Name

Contact Title

Contact Department

Address Line 1

Address Line 2

City, State, Zip

Phone Number

E-Mail Address

By signing below, we acknowledge the importance of timely and accurate submission of the

aggregate financial data calls which are used for workers’ compensation ratemaking in the

Commonwealth of Massachusetts. To the best of our knowledge and belief, the aggregate financial

data calls listed below accurately represent our premium, loss, and expense experience.

Call Number

Call Name

Due Date

2, 2A, 2C, 2D, 2E Policy Year Calls March 15

3, 3A, 3C Accident Year Calls April 1

4 Reconciliation Report April 1

5 Residual Market Direct Written Premium Call April 1

5A Large Deductible Company Level Written Premium April 1

5B Direct Written Premium Call April 1

6 MA Calendar Year Expense Data May 15

6A Insurance Expense Exhibit April 15

7 Large Loss and Catastrophe Call April 15

_____________________________________ _________________________________

Signature Date

This completed form must be received by the WCRIBMA’s Data Operations Department no later than

June 1, ______.

PART II

AGGREGATE FINANCIAL REPORTING

SECTION IV

ANNUAL CALLS

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Part II – Aggregate Financial Reporting PY General Instructions Page: 1

SECTION IV – ANNUAL CALLS

POLICY YEAR CALLS – GENERAL INSTRUCTIONS

Policy Year Calls: Calls # 2, 2A, 2C, 2D, 2E

Data Period: Policy Year data

Due Date: March 15

A. General Description

These are calls for Massachusetts workers’ compensation experience summarized by policy year.

B. General Instructions (Applies to all Policy Year Calls)

1. Report aggregate totals (inception to date totals). Consequently, no premium, paid loss, or claim

count values should be less than zero.

2. Massachusetts claims are those that relate to Massachusetts exposures used to calculate

Massachusetts premiums. See Part III – Definitions

for further details.

3. Report all loss amounts on a first dollar basis. In other words, for any policies having deductibles,

report the loss amounts gross, before any deductible offset. This applies to:

• Massachusetts Benefits Deductible Premium Credit

• Massachusetts Benefits Claim and Aggregate Deductible Premium Credit

• Independently filed large or small deductible programs

4. The following experience should not be included in these calls:

• Excess Workers’ Compensation (written over a self-insured retention)

• National Defense Projects Rating Plan

• Terrorism Insurance Program (Certified Acts of Terrorism) Premium

5. The following fields must always be positive:

• Earned Premiums (Columns 1-3)

• Indemnity Paid (Column 4)

• Medical Paid (Column 5)

• Indemnity Case Reserves (Column 6)

• Medical Case Reserves (Column 7)

• Incurred Indemnity Claim Count – Closed (with payment) (Column 11)

• Incurred Indemnity Claim Count – Open (Outstanding) (Column 12)

• Defense and Cost Containment Expense Paid (Column 13)

• Defense and Cost Containment Expense Case (Column 14)

• Premium Adjustment due to ARAP Surcharge (Column 15)

The following fields must always be negative:

• Premium Adjustments due to Construction Credit (Column 16)

• Premium Adjustments due to QLMP Credit (Column 17)

• Premium Adjustments due to Scheduled Rating Plans (Column 18)

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6. Policy Year calls earned premiums (columns 1, 2 and 3) should include audit accruals. If these

amounts are not estimated at policy year level then make a reasonable allocation. Any future

audit accruals allocation should be consistent with prior allocations.

7. Policy Year calls net earned premium (column 3) should include retrospective rating accruals.

C. Row Instructions (Applies to all Policy Year Calls):

• For each Line A-V, report the cumulative premium, paid losses, claim counts, and paid DCC from

the date of policy inception to 12/31 of the current reporting year. Report loss reserves and DCC

reserves as of December 31 of the current reporting year.

• For Line A, report all years prior to the twenty plus current.

• Line X is a calculated row; it is the sum of Lines A-V.

• For Line Y, report the prior year’s call Line X.

• Line Z is a calculated row; it is the difference of Line X minus Line Y. This is the calendar year

total for the current year.

D. Column Instructions (Applies to all Policy Year Calls):

Column 1: Policy Year Accumulated Earned Premium – Standard at Bureau DSR Level

Column 2: Policy Year Accumulated Earned Premium – Standard at Company Level

Column 3: Policy Year Accumulated Earned Premium – Net

Column 4: Accumulated Policy Year – Paid Indemnity

Column 5: Accumulated Policy Year – Paid Medical

Column 6: Accumulated Policy Year – Case Reserves Indemnity

Column 7: Accumulated Policy Year – Case Reserves Medical

Column 8: Indemnity and Medical Total Paid Losses - MAFDRA and the MAFDRA templates will

calculate Column 8 as Columns 4 and 5 are entered.

Column 9: Indemnity and Medical Total Case Reserves - MAFDRA and the MAFDRA templates

will calculate Column 9 as Columns 6 and 7 are entered.

Column 10: Indemnity and Medical Total Case Incurred Losses - MAFDRA and the MAFDRA

templates will calculate Column 10 as Columns 8 and 9 are entered.

Column 11: Policy Year Incurred Indemnity Claim Count – Accumulated Closed (with payment)

Column 12: Policy Year Incurred Indemnity Claim Count – Open (Outstanding)

Column 13: Accumulated Policy Year Defense and Cost Containment Expense – Paid

Column 14: Accumulated Policy Year Defense and Cost Containment Expense – Case Reserves

Column 15: Premium Adjustments Due to ARAP Surcharge

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Part II – Aggregate Financial Reporting PY General Instructions Page: 3

Column 16: Premium Adjustments Due to Construction Credit Program (MA CCPAP)

Column 17: Premium Adjustments Due to QLMP Credit

Column 18: Premium Adjustments Due to Scheduled Rating Plans

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Part II – Aggregate Financial Reporting Page 2:1

CALL # 2 – POLICY YEAR CALL

A. Call Specific Description

Report Massachusetts workers’ compensation experience excluding large deductible policies.

B. Call Specific Instructions (Applies in addition to Policy Year Calls General Instructions

)

1. Report premium and loss amounts for the current policy year and the twenty policy years prior to

the current policy year. For earlier policy years, combine the data and report on the “All Prior

Combined” line.

2. Reporting of the following elements is only required for policy years 1994 and subsequent:

• Incurred Indemnity Claim Count - Accumulated Closed (with payment) (column 11)

• Incurred Indemnity Claim Count - Open Outstanding (column 12)

• Defense and Cost Containment Expenses Paid (column 13)

• Defense and Cost Containment Expenses Case Reserves (column 14)

• Premium Adjustments due to Scheduled Rating Plans (column 18)

3. Exclude the following experience when compiling the data for this call:

• Excess Workers’ Compensation (written over a self-insured retention)

• National Defense Projects Rating Plan

• Terrorism Insurance Program (Certified Acts of Terrorism) Premium

• F Classification experience

• Maritime experience for all policies effective January 1, 2006 and later

• Large Deductible experience

CALL #2 – POLICY YEAR CALL

(1)

(2)

(3)

(4)

(5)

(6)

(7)

Policy Year Accumulated Earned Premium

Paid Case Reserves

Standard at Bureau

Designated Statistical

Reporting Level

Standard at

Company Level

Net

Indemnity

Medical

Indemnity

Medical

Line

Report

Level

Policy Year

Valued

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E.

17th

XXXX - 17

F.

16th

XXXX - 16

G.

15th

XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K. 11th XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 1 of 3

CALL #2 – POLICY YEAR CALL

(8)

(9)

(10)

(11)

(12)

(13)

(14)

Line

Indemnity and Medical – Total Losses

Policy Year Incurred

Indemnity Claim Count

Accumulated Policy Year

Defense and Cost Containment

Expense

Report

Policy Year

Being

Paid

Case Reserves

Case Incurred

Losses

Accumulated

Closed

(with payment)

Open

Outstanding

Paid

Case Reserves

Level

Valued

(4)+(5)

(6)+(7)

(8)+(9)

A.

All Prior

Combined

Prior to

XXXX - 20

B.

20th

XXXX - 20

C. 19th

XXXX - 19

D. 18th

XXXX - 18

E. 17th

XXXX - 17

F. 16th

XXXX - 16

G. 15th

XXXX - 15

H. 14th

XXXX - 14

I. 13th

XXXX - 13

J. 12th

XXXX - 12

K. 11th

XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T.

2nd

XXXX - 2

U.

1st

XXXX - 1

V.

Current

XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 2 of 3

CALL #2 – POLICY YEAR CALL

(15)

(16)

(17)

(18)

Line

Premium Adjustments

Report

Level

Policy Year

Being

Valued

Due to ARAP

Surcharge

Due to

Construction

Credit Program

Due to

QLMP Credit

Due to Scheduled

Rating Plans

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K. 11th XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 3 of 3

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Part II – Aggregate Financial Reporting Page 2A:1

CALL #2A: POLICY YEAR RESIDUAL MARKET CALL

A. Call Specific Description

Report all Massachusetts workers’ compensation residual market experience.

The Massachusetts residual market is made up of the following:

• Massachusetts Assigned Risk Pool

• Voluntary Direct Assigned Risks

B. Call Specific Instructions (Applies in addition to Policy Year Calls General Instructions

)

1. The Massachusetts Assigned Risk Pool assigns residual market policies to either a servicing

carrier or to a voluntary direct assignment carrier. Both types of policies are to be reported.

2. Report premium and loss amounts for the policy years 1989 and subsequent.

3. Reporting of the following elements is only required for policy years 1994 and subsequent:

• Incurred Indemnity Claim Count – Accumulated Closed (with payment) (column 11)

• Incurred Indemnity Claim Count – Open Outstanding (column 12)

• Defense and Cost Containment Expenses Paid (column 13)

• Defense and Cost Containment Expenses Case Reserves (column 14)

4. Exclude the following experience when compiling the data for this call:

• Excess Workers’ Compensation (written over a self-insured retention)

• National Defense Projects Rating Plan

• Terrorism Insurance Program (Certified Acts of Terrorism) Premium

• F Classification experience

• Maritime experience for all policies effective January 1, 2006 and later

CALL #2A – POLICY YEAR RESIDUAL MARKET CALL

(1)

(2)

(3)

(4)

(5)

(6)

(7)

Policy

Policy Year Accumulated Earned Premium

Paid Case Reserves

Year

Standard at Bureau

Report

Being

Designated Statistical Standard at Net Indemnity Medical Indemnity Medical

Line

Level

Valued

Reporting Level

Company Level

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D.

18th

XXXX - 18

E.

17th

XXXX - 17

F.

16th

XXXX - 16

G.

15th

XXXX – 15

H.

14th

XXXX - 14

I.

13th

XXXX - 13

J.

12th

XXXX - 12

K.

11th

XXXX - 11

L.

10th

XXXX - 10

M.

9th

XXXX - 9

N.

8th

XXXX - 8

O.

7th

XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 1 of 3

CALL #2A – POLICY YEAR RESIDUAL MARKET CALL

(8)

(9)

(10)

(11)

(12)

(13)

(14)

Line

Indemnity and Medical – Total Losses

Policy Year Incurred

Indemnity Claim Count

Accumulated Policy Year

Defense and Cost Containment

Expense

Report

Policy Year

Being

Paid

Case Reserves

Case Incurred

Losses

Accumulated

Closed

(with payment)

Open

Outstanding

Paid

Case Reserves

Level

Valued

(4)+(5)

(6)+(7)

(8)+(9)

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K. 11th XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q.

5th

XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 2 of 3

CALL #2A – POLICY YEAR RESIDUAL MARKET CALL

(15)

(16)

(17)

(18)

Line

Premium Adjustments

Report

Level

Policy Year

Being

Valued

Due to ARAP

Surcharge

Due to

Construction

Credit Program

Due toQLMP

Credit

Due to Scheduled

Rating Plans

A.

All Prior

Combined

Prior to

XXXX - 20

B.

20th

XXXX - 20

C.

19th

XXXX - 19

D.

18th

XXXX - 18

E.

17th

XXXX - 17

F.

16th

XXXX - 16

G.

15th

XXXX - 15

H.

14th

XXXX - 14

I.

13th

XXXX - 13

J.

12th

XXXX - 12

K.

11th

XXXX - 11

L.

10th

XXXX - 10

M.

9th

XXXX - 9

N.

8th

XXXX - 8

O.

7th

XXXX - 7

P.

6th

XXXX - 6

Q.

5th

XXXX - 5

R.

4th

XXXX - 4

S.

3rd

XXXX - 3

T.

2nd

XXXX - 2

U.

1st

XXXX - 1

V.

Current

XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 3 of 3

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section IV

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting Page 2C:1

CALL #2C: POLICY YEAR LARGE DEDUCTIBLE CALL

A. Call Specific Description

Report Massachusetts workers’ compensation large deductible experience summarized by policy year.

In Massachusetts, large deductibles are defined as policies with per claim deductibles of at least

$75,000

1

.

B. Call Specific Instructions (Applies in addition to Policy Year Calls General Instructions

)

1. Report premium and loss amounts for policy years 1990 and subsequent.

2. Reporting of the following elements is only required for policy years 1994 and subsequent:

• Incurred Indemnity Claim Count – Accumulated Closed (with payment) (column 11)

• Incurred Indemnity Claim Count – Open Outstanding (column 12)

• Defense and Cost Containment Expenses Paid (column 13)

• Defense and Cost Containment Expenses Case Reserves (column 14)

3. Effective January 1, 2007 report:

• Premium Adjustments due to Schedule Rating Plans (column 18).

4. Policies with provisions for the Massachusetts Benefits Deductible Premium Credit or the

Massachusetts Benefits Claim and Aggregate Deductible Premium Credit are not to be reported

on this call.

5. Exclude the following experience when compiling the data for this call:

• Excess Workers’ Compensation (written over a self-insured retention)

• National Defense Projects Rating Plan

• Terrorism Insurance Program (Certified Acts of Terrorism) Premium

• F Classification experience

• Maritime experience for all policies effective January 1, 2006 and later

• Residual Market Experience

1

Prior to May 1, 2003 the per claim deductible for a large deductible policy had to be at least $100,000. Effective May

1, 2003, the minimum per claim deductible for a large deductible policy was reduced to $75,000.

CALL #2C – POLICY YEAR LARGE DEDUCTIBLE CALL

(1)

(2)

(3)

(4)

(5)

(6)

(7)

Policy

Policy Year Accumulated Earned Premium

Paid Case Reserves

Year

Standard at Bureau

Report

Being

Designated Statistical

Standard at

Net

Indemnity

Medical

Indemnity

Medical

Line

Level

Valued

Reporting Level

Company Level

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K. 11th XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 1 of 3

CALL #2C – POLICY YEAR LARGE DEDUCTIBLE CALL

(8)

(9)

(10)

(11)

(12)

(13)

(14)

Line

Indemnity and Medical – Total Losses

Policy Year Incurred

Indemnity Claim Count

Accumulated Policy Year

Defense and Cost Containment

Expense

Report

Policy Year

Being

Paid

Case Reserves

Case Incurred

Losses

Accumulated

Closed

(with payment)

Open

Outstanding

Paid

Case Reserves

Level

Valued

(4)+(5)

(6)+(7)

(8)+(9)

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K. 11th XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 2 of 3

CALL #2C – POLICY YEAR LARGE DEDUCTIBLE CALL

(15)(15) (16) (17) (18)

Line

Premium Adjustments

Report

Level

Policy Year

Being

Valued

Due to ARAP

Surcharge

Due to

Construction

Credit Program

Due to

QLMP Credit

Due to Scheduled

Rating Plans

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K. 11th XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 3 of 3

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section IV

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting Page 2D:1

CALL #2D: POLICY YEAR “F” CLASSIFICATION CALL

A. Call Specific Description

Report Massachusetts workers’ compensation “F” classification experience.

B. Call Specific Instructions (Applies in addition to Policy Year Calls General Instructions

)

1. The policy year call makes a distinction between Federal “F” Classification and Non “F”

Classification. The policy year call does not make a distinction between USL&HW and Non

USL&HW. Even if the rate for a Non “F” Classification code has been modified by the USL&HW

premium multiplier, it should not be classified as “F” Classification.

2. Report premium and loss amounts for the current policy year and the twenty policy years prior to

the current policy year. For earlier policy years, combine the data and report on the “All Prior

Combined” line.

3. Effective January 1, 2007, “F” classification experience for policy years 2006 and subsequent is to

be reported on an individual classification-by-classification basis.

For policy years 2005 and prior, report “F” classification experience in the same manner as reported

previously.

4. For a complete listing of all classification codes, refer to the rate table in the

Massachusetts

Workers Compensation and Employers Liability Insurance Manual.

5. Reporting of the following elements is only required for policy years 1994 and subsequent:

• Incurred Indemnity Claim Count - Accumulated Closed (with payment) (column 11)

• Incurred Indemnity Claim Count - Open Outstanding (column 12)

• Defense and Cost Containment Expenses Paid (column 13)

• Defense and Cost Containment Expenses Case Reserves (column 14)

6. Effective January 1, 2007 report:

• Premium Adjustments due to Schedule Rating Plans (column 18).

7. Exclude the following experience when compiling the data for this call:

• Excess Workers’ Compensation (written over a self-insured retention)

• National Defense Projects Rating Plan

• Terrorism Insurance Program (Certified Acts of Terrorism) Premium

• Maritime Experience

CALL #2D - POLICY YEAR “F” CLASSIFICATION CALL

(1)

(2)

(3)

(4)

(5)

(6)

(7)

Policy

Policy Year Accumulated Earned Premium

Paid Case Reserves

Year

Standard at Bureau

Report

Being

Designated Statistical

Standard at

Net

Indemnity

Medical

Indemnity

Medical

Line

Level

Valued

Reporting Level

Company Level

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K. 11th XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 1 of 3

CALL #2D - POLICY YEAR “F” CLASSIFICATION CALL

(8)

(9)

(10)

(11)

(12)

(13)

(14)

Line

Indemnity and Medical – Total Losses

Policy Year Incurred

Indemnity Claim Count

Accumulated Policy Year

Defense and Cost Containment

Expense

Report

Policy Year

Being

Paid

Case Reserves

Case Incurred

Losses

Accumulated

Closed

(with payment)

Open

Outstanding

Paid

Case Reserves

Level

Valued

(4)+(5)

(6)+(7)

(8)+(9)

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K. 11th XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 2 of 3

CALL #2D - POLICY YEAR “F” CLASSIFICATION CALL

(15) (16) (17) (18)

Line

Premium Adjustments

Report

Level

Policy Year

Being

Valued

Due to ARAP

Surcharge

Due to

Construction

Credit Program

Due to

QLMP Credit

Due to Scheduled

Rating Plans

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K. 11th XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 3 of 3

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section II

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting Page 2E:1

CALL #2E: POLICY YEAR MARITIME CLASSIFICATION CALL

A. Call Specific Description

Report Massachusetts workers’ compensation maritime experience summarized by policy year.

See Part III – Definitions

for further details about maritime experience.

B. Call Specific Instructions (Applies in addition to Policy Year Calls General Instructions

)

1. Report premium and loss amounts for the policy years 2006 and subsequent. Maritime

experience for policy years prior to policy year 2006 is to be excluded from this call.

2. Exclude the following experience when compiling the data for this call:

• Excess Workers’ Compensation (written over a self-insured retention)

• National Defense Projects Rating Plan

• Terrorism Insurance Program (Certified Acts of Terrorism) Premium

• F Classification experience

CALL #2E - POLICY YEAR MARITIME CLASSIFICATION CALL

(1)

(2)

(3)

(4)

(5)

(6)

(7)

Policy

Policy Year Accumulated Earned Premium

Paid Case Reserves

Year

Standard at Bureau

Report

Being

Designated Statistical

Standard at

Net

Indemnity

Medical

Indemnity

Medical

Line

Level

Valued

Reporting Level

Company Level

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K. 11th XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 1 of 3

CALL #2E - POLICY YEAR MARITIME CLASSIFICATION CALL

(8)

(9)

(10)

(11)

(12)

(13)

(14)

Line

Indemnity and Medical – Total Losses

Policy Year Incurred

Indemnity Claim Count

Accumulated Policy Year

Defense and Cost Containment

Expense

Report

Policy Year

Being

Paid

Case Reserves

Case Incurred

Losses

Accumulated

Closed

(with payment)

Open

Outstanding

Paid

Case Reserves

Level

Valued

(4)+(5)

(6)+(7)

(8)+(9)

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K. 11th XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 2 of 3

CALL #2E - POLICY YEAR MARITIME CLASSIFICATION CALL

(15) (16) (17)) (18)

Line

Premium Adjustments

Report

Level

Policy Year

Being

Valued

Due to ARAP

Surcharge

Due to

Construction

Credit Program

Due to

QLMP Credit

Due to Scheduled

Rating Plans

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K. 11th XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 3 of 3

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section IV

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting AY General Instructions Page: 1

ACCIDENT YEAR CALLS – GENERAL INSTRUCTIONS

Accident Year Calls: Calls # 3, 3A, 3C

Data Period: Accident Year data

Due Date: April 1

A. General Description

These are calls for Massachusetts workers’ compensation experience summarized by accident year.

B. General Instructions (Applies to all Accident Year Calls)

1. Report aggregate totals (inception to date totals). Consequently, no paid loss or claim count

values should be less than zero.

2. Massachusetts claims are those that relate to Massachusetts exposures used to calculate

Massachusetts premiums. See Part III - Definitions

for further details.

3. Report all loss amounts on a first dollar basis. In other words, for any policies having deductibles,

report the loss amounts gross, before any deductible offset. This applies to:

• Massachusetts Benefits Deductible Premium Credit

• Massachusetts Benefits Claim and Aggregate Deductible Premium Credit

• Independently filed large or small deductible programs

4. The following experience should not be included in these calls:

• Excess Workers’ Compensation (written over a self-insured retention)

• National Defense Projects Rating Plan

• F Classification experience

• Maritime experience for all policies effective January 1, 2006 and later

5. The following fields must always be positive:

• Indemnity Paid (Column 1)

• Medical Paid (Column 2)

• Indemnity Case Reserves (Column 3)

• Medical Case Reserves (Column 4)

• Incurred Indemnity Claim Count: Closed (with payment) (Column 8)

• Incurred Indemnity Claim Count – Open (Outstanding) (Column 9)

• Defense and Cost Containment Expense Paid (Column 10)

• Defense and Cost Containment Expense Case Reserves (Column 11)

C. Row (Line) Instructions (Applies to all Accident Year Calls):

• For each Line A-V, report the cumulative paid losses from the date of accident through December

31 of the current reporting year. Report loss reserves or claim counts as of December 31 of the

current reporting year.

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section IV

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting AY General Instructions Page: 2

• For Line A, report all years prior to the twenty plus current.

• Line X is a calculated row; it is the sum of Lines A-V.

• For Line Y, report the prior year’s call Line X.

• Line Z is a calculated row; it is the difference of Line X minus Line Y. This is the calendar year

total for the current year.

D. Column Instructions (Applies to all Accident Year Calls):

Column 1: Accumulated Accident Year – Paid Indemnity

Column 2: Accumulated Accident Year – Paid Medical

Column 3: Accumulated Accident Year – Case Reserves Indemnity

Column 4: Accumulated Accident Year – Case Reserves Medical

Column 5: Indemnity and Medical Total Paid Losses - MAFDRA and the MAFDRA templates will

calculate Column 5 as Columns 1 and 2 are entered.

Column 6: Indemnity and Medical Total Case Reserves - MAFDRA and the MAFDRA templates

will calculate Column 6 as Columns 3 and 4 are entered.

Column 7: Indemnity and Medical Total Case Incurred losses - MAFDRA and the MAFDRA

templates will calculate Column 7 as Columns 5 and 6 are entered.

Column 8: Accident Year Incurred Indemnity Claim Count – Accumulated Closed (with payment)

Column 9: Accident Year Incurred Indemnity Claim Count – Open (Outstanding)

Column 10: Accumulated Accident Year Defense and Cost Containment Expense – Paid

Column 11: Accumulated Accident Year Defense and Cost Containment Expense – Case Reserves

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section IV

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting Page 3:1

CALL #3 – ACCIDENT YEAR CALL

A. Call Specific Description

Report Massachusetts workers’ compensation experience excluding large deductible policies

summarized by accident year.

B. Call Specific Instructions (Applies in addition to Accident Year Calls General Instructions

)

1. Report loss amounts for the current accident year and the twenty accident years prior to the

current accident year. For earlier accident years, combine the data and report on the “All Prior

Combined” line.

2. Reporting of the following elements is only required for accident years 1994 and subsequent:

• Incurred Indemnity Claim Count - Accumulated Closed (with payment) (column 8)

• Incurred Indemnity Claim Count - Open (Outstanding) (column 9)

• Defense and Cost Containment Expenses Paid (column 10)

• Defense and Cost Containment Expenses Case Reserves (column 11)

3. Exclude the following experience when compiling the data for this call:

• Excess Workers’ Compensation (written over a self-insured retention)

• National Defense Projects Rating Plan

• F Classification experience

• Maritime experience for all policies effective January 1, 2006 and later

• Large Deductible experience

CALL #3 – ACCIDENT YEAR CALL

(1)

(2)

(3)

(4)

(5)

(6)

(7)

Line

Accident

Year Being

Valued

Paid

Case Reserves

Indemnity and Medical – Total Losses

Report

Level

Indemnity Medical Indemnity Medical

Paid

Case Reserves

Case Incurred

Losses

(1)+(2)

(3)+(4)

(5)+(6)

A.

All Prior

Combined

Prior to

XXXX - 20

B.

20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H. 14th XXXX - 14

I.

13th

XXXX - 13

J.

12th

XXXX - 12

K.

11th

XXXX - 11

L.

10th

XXXX - 10

M.

9th

XXXX - 9

N.

8th

XXXX - 8

O.

7th

XXXX - 7

P.

6th

XXXX - 6

Q.

5th

XXXX - 5

R.

4th

XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 1 of 2

CALL #3 – ACCIDENT YEAR CALL

(8)

(9)

(10)

(11)

Line

Accident Year Incurred Indemnity Claim

Count

Accumulated Accident Year Defense and

Cost Containment Expense

Report

Level

Accident

Year Being

Valued

Accumulated

Closed

(with payment)

Open Outstanding Paid Case Reserves

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K. 11th XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 2 of 2

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section IV

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting Page 3A:1

CALL # 3A – ACCIDENT YEAR RESIDUAL MARKET CALL

A. Call Specific Description

Report Massachusetts workers’ compensation residual market experience summarized by accident

year.

The Massachusetts residual market is made up of the following:

• Massachusetts Assigned Risk Pool

• Voluntary Direct Assigned Risks

B. Call Specific Instructions (Applies in addition to Accident Year Calls General Instructions

)

1. The Massachusetts Assigned Risk Pool assigns residual market policies to either a servicing

carrier or to a voluntary direct assignment carrier. Both types of policies are to be reported.

2. Report loss amounts for the accident years 1989 and subsequent.

3. Reporting of the following elements is only required for accident years 1994 and subsequent:

• Incurred Indemnity Claim Count – Accumulated Closed (with payment) (column 8)

• Incurred Indemnity Claim Count – Open Outstanding (column 9)

• Defense and Cost Containment Expenses Paid (column 10)

• Defense and Cost Containment Expenses Case Reserves (column 11)

4. Exclude the following experience when compiling the data for this call:

• Excess Workers’ Compensation (written over a self-insured retention)

• National Defense Projects Rating Plan

• “F” Classification experience

• Maritime experience for all policies effective January 1, 2006 and later

CALL #3A – ACCIDENT YEAR RESIDUAL MARKET CALL

(1)

(2)

(3)

(4)

(5)

(6)

(7)

Line

Accident

Year Being

Valued

Paid

Case Reserves

Indemnity and Medical – Total Losses

Report

Level

Indemnity Medical Indemnity Medical

Paid

Case Reserves

Case Incurred

Losses

(1)+(2)

(3)+(4)

(5)+(6)

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C.

19th

XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G.

15th

XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K.

11th

XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O.

7th

XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S.

3rd

XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 1 of 2

CALL #3A – ACCIDENT YEAR RESIDUAL MARKET CALL

(8)

(9)

(10)

(11)

Line

Accident Year Incurred Indemnity Claim

Count

Accumulated Accident Year Defense and

Cost Containment Expense

Report

Level

Accident

Year Being

Valued

Accumulated

Closed

(with payment)

Open Outstanding Paid Case Reserves

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K. 11th XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 2 of 2

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section IV

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting Page 3C:1

CALL # 3C– ACCIDENT YEAR LARGE DEDUCTIBLE CALL

A. Call Specific Description

Report Massachusetts workers’ compensation large deductible experience summarized by accident

year. In Massachusetts, large deductibles are defined as policies with per claim deductibles of at least

$75,000

2

.

B. Call Specific Instructions (Applies in addition to Accident Year Calls General Instructions

)

1. Report loss amounts for accident years 1990 and subsequent.

2. Reporting of the following elements is only required for accident years 1994 and subsequent:

• Incurred Indemnity Claim Count – Accumulated Closed (with payment) (column 8)

• Incurred Indemnity Claim Count – Open Outstanding (column 9)

• Defense and Cost Containment Expenses Paid (column 10)

• Defense and Cost Containment Expenses Case Reserves (column 11)

3. Policies with provisions for the Massachusetts Benefits Deductible Premium Credit or the

Massachusetts Benefits Claim and Aggregate Deductible Premium Credit are not to be reported

on this call.

4. Exclude the following experience when compiling the data for this call:

• Excess Workers’ Compensation (written over a self-insured retention)

• National Defense Projects Rating Plan

• F Classification experience

• Maritime experience for all policies effective January 1, 2006 and later

• Residual Market Experience

2

Prior to May 1, 2003 the per claim deductible for a large deductible policy had to be at least $100,000. Effective May

1, 2003, the minimum per claim deductible for a large deductible policy was reduced to $75,000.

CALL #3C – ACCIDENT YEAR LARGE DEDUCTIBLE CALL

(1)

(2)

(3)

(4)

(5)

(6)

(7)

Line

Accident

Year Being

Valued

Paid

Case Reserves

Indemnity and Medical – Total Losses

Report

Level

Indemnity Medical Indemnity Medical

Paid

Case Reserves

Case Incurred

Losses

(1)+(2)

(3)+(4)

(5)+(6)

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C.

19th

XXXX - 19

D.

18th

XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H.

14th

XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K.

11th

XXXX - 11

L.

10th

XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O.

7th

XXXX - 7

P.

6th

XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T.

2nd

XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 1 of 2

CALL #3C – ACCIDENT YEAR LARGE DEDUCTIBLE CALL

(8)

(9)

(10)

(11)

Line

Accident Year Incurred Indemnity Claim

Count

Accumulated Accident Year Defense and

Cost Containment Expense

Report

Level

Accident

Year Being

Valued

Accumulated

Closed

(with payment)

Open Outstanding Paid Case Reserves

A.

All Prior

Combined

Prior to

XXXX - 20

B. 20th XXXX - 20

C. 19th XXXX - 19

D. 18th XXXX - 18

E. 17th XXXX - 17

F. 16th XXXX - 16

G. 15th XXXX - 15

H. 14th XXXX - 14

I. 13th XXXX - 13

J. 12th XXXX - 12

K. 11th XXXX - 11

L. 10th XXXX - 10

M. 9th XXXX - 9

N. 8th XXXX - 8

O. 7th XXXX - 7

P. 6th XXXX - 6

Q. 5th XXXX - 5

R. 4th XXXX - 4

S. 3rd XXXX - 3

T. 2nd XXXX - 2

U. 1st XXXX - 1

V. Current XXXX

X.

Total to Current 12/31

Sum (A) to (V)

Y.

Total to Prior 12/31

Sum (A) to (V)

Z.

Calendar Year

Experience (X-Y)

Page 2 of 2

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section IV

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting Page 4:2

CALL #4: RECONCILIATION REPORT

Data Period: Calendar Year data

Due Date: April 1

st

A. Description

The report compares the net earned premium and incurred losses reported on the policy year and

accident year calls to the Exhibit of Premium and Losses of the Annual Statement (Statutory Page

14) and also the standard earned premium data to the net earned premium reported to the

WCRIBMA.

B. Reporting Requirements

1. Page 1 reconciles the net earned premium from the policy year calls to the Exhibit of Premium and

Losses of the Annual Statement (Statutory Page 14 data, Line 16 column 2). All reconcilable items

must be identified and explained.

2. Page 2 reconciles the Incurred Losses from the Policy Year and Accident Year Calls to the Exhibit

of Premium and Losses of the Annual Statement (Statutory Page 14 data, Line 16 column 6). All

reconcilable items must be identified and explained.

3. Page 3 reconciles the Standard Earned Premium at DSR Level to the Net Earned Premium from

the Policy Year Calls. Differences exceeding $500 must be reconciled. All reconcilable items must

be identified and explained.

4. Submit the reconciliation report on same carrier or carrier group basis as the Policy Year and

Accident Year calls.

Earned Premium Reconciliation Report (Page 1 of 3)

Line 1: Total Market Net Premium, Policy Year Call (Call #2), Line Z, column (3).

Line 2: Total Market Premium Adjustments due to ARAP Surcharge, Policy Year Call (Call #2),

Line Z, column (15).

Line 3: Total Market Premium Adjustments due to QLMP Credit, Policy Year Call (Call #2), Line

Z, column (17).

Line 4: Large Deductible Net Premium, Policy Year Large Deductible Call (Call #2C), Line Z,

column (3).

Line 5: Large Deductible Premium Adjustments due to ARAP Surcharge, Policy Year Large

Deductible (Call #2C), Line Z, column (15).

Line 6: “F” Classification Net Premium, Policy Year “F” Classification Call (Call #2D), Line Z,

column (3).

Line 7: “F” Classification Premium Adjustments due to ARAP Surcharge, Policy Year “F”

Classification Call (Call #2D), Line Z, column (15).

Line 8: “F” Classification Premium Adjustments due to QLMP Credit, Policy Year “F”

Classification Call (Call #2D), Line Z, column (17).

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section IV

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting Page 4:2

Line 9: Maritime Classification Net Premium, Policy Year Maritime Classification Call (Call #2E),

Line Z, column (3).

Line 10: Maritime Classification Premium Adjustments due to ARAP Surcharge, Policy Year

Maritime Classification Call (Call #2E), Line Z, column (15).

Line 11: Maritime Classification Premium Adjustments due to QLMP Credit, Policy Year Maritime

Classification Call (Call #2E), Line Z, column (17).

Line 12: Sum of Lines 1 through 11.

Line 13: National Defense Projects.

Line 14: Terrorism Insurance Program (Certified Acts of Terrorism) Premium.

Line 15: Subtotal of Lines 13 and 14.

Line 16: Annual Statement Earned Premium, Exhibit of Premium and Losses (Statutory Page 14

data), Line 16, Column 2.

Line 17: Difference of (Line 16 – Line 15 – Line 12).

Line 18: “Write-Ins” Reconciliation Item

Line 19: “Write-Ins” Reconciliation Item.

Line 20: “Write-Ins” Reconciliation Item.

Line 21: “Write-Ins” Reconciliation Item.

Line 22: “Write-Ins” Reconciliation Item.

Line 23: Sum of Lines 18 through 22.

Line 24: Difference of (Line 23 – Line 17)

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section IV

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting Page 4:3

Incurred Loss Reconciliation Report (Page 2 of 3)

Line 1: Calendar Year Case Incurred Losses. Column (1) from Line Z, column (13) of Policy Year

Call (Call #2). Column (2) from Line Z, column (10) of Accident Year Call (Call #3).

Line 2: Large Deductible Case Incurred Losses. Column (1) from Line Z, column (13) of Policy

Year Large Deductible Call (Call #2C). Column (2) from Line Z, column (10) of Accident

Year Large Deductible Call (Call #3C).

Line 3: “F” Classification Case Incurred Losses; Policy Year “F” Classification Call (Call #2D),

Line Z, column (13).

Line 4: Maritime Classification Case Incurred Losses; Policy Year Maritime Classification Call

(Call #2E), Line Z, column (13).

Line 5: Sum of Lines 1 through 4

Line 6: National Defense Projects

Line 7: Deductible Reimbursements (Large)

Line 8: Deductible Reimbursements (Small)

Line 9: Sections 7, 8, 10, 13A and 14 penalties

Line 10: Incurred But Not Reported (IBNR) Reserves

Line 11: DCC on Employers Liability Claims

Line 12: Sum of Lines 6 through 11

Line 13: Annual Statement Incurred Loss, Exhibit of Premium and Losses (Statutory Page 14

data), Line 16, Column 6.

Line 14: Difference of (Line 13 – Line 12 – Line 5)

Line 15: “Write-Ins” Reconciliation Item

Line 16: “Write-Ins” Reconciliation Item

Line 17: “Write-Ins” Reconciliation Item

Line 18: “Write-Ins” Reconciliation Item

Line 19: “Write-Ins” Reconciliation Item

Line 20: Sum of Lines 15 through 19

Line 21: Difference of (Line 20 – Line 14)

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section IV

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting Page 4:5

Net Premium Reconciliation Report (Page 3 of 3)

Line 1: Total Market Calendar Year Earned Premium; Standard at Bureau Designated Statistical

Reporting Level. Policy Year Call (Call #2), Line Z column (1).

Line 2: Large Deductible Calendar Year Earned Premium; Standard at Bureau Designated

Statistical Reporting Level. Policy Year Large Deductible Call (Call #2C), Line Z column

(1).

Line 3: “F” Classification Calendar Year Earned Premium; Standard at Bureau Designated

Statistical Reporting Level. Policy Year “F” Classification Call (Call #2D), Line Z column

(1).

Line 4: Maritime Classification Calendar Year Earned Premium; Standard at Bureau Designated

Statistical Reporting Level. Policy Year Maritime Classification Call (Call #2E), Line Z

column (1).

Line 5: Sum of Lines 1 through 4.

Line 6: Rate Deviations.

Line 7: Premium discounts.

Line 8: Large Deductible Premium Credits.

Line 9: Massachusetts Benefits Deductible Premium Credit.

Line 10: Massachusetts Benefits Claim and Aggregate Deductible Premium Credit.

Line 11: Retrospective Rating Adjustments.

Line 12: Scheduled Rating Adjustments.

Line 13: Sum of Lines 6 through 12.

Line 14: Sum of Lines 5 and 13.

Line 15: Total Market Calendar Year Net Premium. Policy Year Call (Call #2), Line Z, column (3).

Line 16: Large Deductible Calendar Year Net Premium. Policy Year Large Deductible Call (Call

#2C), Line Z, column (3).

Line 17: “F” Classification Calendar Year Net Premium. Policy Year “F” Classification Call (Call

#2D), Line Z, column (3).

Line 18: Maritime Classification Calendar Year Net Premium. Policy Year Maritime Classification

Call (Call #2E), Line Z, column (3).

Line 19: Sum of Lines 15 through 18.

Line 20: Difference of (Line 19 – Line 14).

Line 21: “Write-Ins” Reconciliation Item.

Line 22: “Write-Ins” Reconciliation Item.

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section IV

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting Page 4:5

Line 23: “Write-Ins” Reconciliation Item.

Line 24: “Write-Ins” Reconciliation Item.

Line 25: “Write-Ins” Reconciliation Item.

Line 26: Sum of Lines 21 through 25.

Line 27: Difference of (Line 26 – Line 20).

Call # 4 – RECONCILIATION REPORT

This report shows the reconciliation of Earned Premium data reported to the WCRIBMA in response to the current

Calls for Experience and the Massachusetts Exhibit of Premiums & Losses data from the current Annual

Statement. Enter amounts indicated below:

Earned Premium Reconciliation

I. Indicated Calendar Year Results

A. Policy Year Call (Call #2)

1. Net Premium (Line Z, column (3))

2. Premium Adjustments due to ARAP Surcharge (Line Z, column (15))

3. Premium Adjustments due to QLMP Credit (Line Z, column (17))

B. Policy Year Large Deductible Call (Call #2C)

4. Net Premium (Line Z, column (3))

5. Premium Adjustments due to ARAP Surcharge (Line Z, column (15))

C. Policy Year “F” Classification Call (Call #2D)

6. Net Premium (Line Z, column (3))

7. Premium Adjustments due to ARAP Surcharge (Line Z, column (15))

8. Premium Adjustments due to QLMP Credit (Line Z, column (17))

D. Policy Year Maritime Classification Call (Call #2E)

9. Net Premium (Line Z, column (3))

10. Premium Adjustments due to ARAP Surcharge (Line Z, column (15))

11. Premium Adjustments due to QLMP Credit (Line Z, column (17))

12. Subtotal (Lines 1 through 11)

II. Listed Reconciliation Items

13. National Defense Projects

14. Terrorism Insurance Program (Certified Acts of Terrorism) Premium

15. Subtotal (Lines 13 and 14)

III. Annual Statement

16. Exhibit of Premium and Losses (Statutory Page 14 Data),

Line 16, Column 2 (Earned Premium)

IV. Difference

17. Calculate as indicated

(Line 16 – Line 15 – Line 12)

V. “Write-Ins” Reconciliation Items (provide short description below)

18. ______________________________________________________

19. ______________________________________________________

20. ______________________________________________________

21. ______________________________________________________

22. ______________________________________________________

23. Subtotal (Lines 18 through 22)

_____________________

VI. Remaining Variance

24. Imbalance (Line 23 – Line 17)

_____________________

Page 1 of 3

Call # 4 – RECONCILIATION REPORT

This report shows the reconciliation of Case Incurred Loss data reported to the WCRIBMA in response to the

current Calls for Experience and the Massachusetts Exhibit of Premiums & Losses data from the current Annual

Statement. Enter amounts indicated below:

Incurred Loss Reconciliation

Policy Year

(1)

Accident Year

(2)

I. Indicated Calendar Year Results

1. Calendar Year Case Incurred Losses

2. Large Deductible Case Incurred Losses

3. “F” Classification Case Incurred Losses

(from the Policy Year “F” Classification Call)

4. Maritime Classification Case Incurred Losses

( from the Policy Year Maritime Call)

5. Subtotal (Lines 1 through 4)

_________

II. Listed Reconciliation Items

6. National Defense Projects

7. Deductible Reimbursements (Large)

8. Deductible Reimbursements (Small)

9. Sections 7, 8, 10, 13A, and 14 penalties

10. Incurred But Not Reported (IBNR) Reserves

11. DCC on Employers Liability Claims

12. Subtotal (Lines 6 through 11)

__________

III. Annual Statement

13. Exhibit of Premium and Losses (Statutory Page 14

Data), Line 16, Column 6 (Incurred Loss)

__________

IV. Difference

14. Calculate as indicated

(Line 13 – Line 12 – Line 5)

V. “Write-Ins” Reconciliation Items (provide short description

below)

15. _____________________________________

16. _____________________________________

17. _____________________________________

18. _____________________________________

19. _____________________________________

20. Subtotal (Lines 15 through 19)

___________

_________

VI. Remaining Variance

21. Imbalance (Line 20 – Line 14)

Page 2 of 3

Call # 4 – RECONCILIATION REPORT

This report shows the reconciliation of Standard Earned Premium data to the Net Earned Premium reported to the WCRIBMA in

response to the current Calls for Experience. Enter amounts indicated below:

Calendar Year

Earned Premium

I. Calendar Year Standard Premium at Bureau Designated Statistical Reporting Level

1. Policy Year Call – (Line Z, column (1))

2. Policy Year Large Deductible Call – (Line Z, column (1))

3. Policy Year “F” Classification Call – (Line Z, column (1))

4. Policy Year Maritime Classification Call – (Line Z, column (1))

5. Subtotal (Lines 1 through 4)

II. Premium Components:

6. Rate Deviations

7. Premium discounts.

8. Large Deductible Premium Credits with deductible amount of at least $75,000

3

.

9. Massachusetts Benefits Deductible Premium Credit.

10. Massachusetts Benefits Claim and Aggregate Deductible Premium Credit.

11. Retrospective Rating Adjustments

12. Scheduled Rating Adjustments

13. Subtotal (Lines 6 through 12)

_____________

III. Calculated Net Premium

14. Sum Lines 5 and 13

IV. Calendar Year Net Earned Premium

15. Policy Year Call – (Line Z, column (3))

16. Policy Year Large Deductible Call – (Line Z, column (3))

17. Policy Year “F” Classification Call – (Line Z, column (3))

18. Policy Year Maritime Classification Call – (Line Z, column (3))

19. Total Net Earned Premium (Sum Lines 15 through 18)

V. Difference

20. Calculate as indicated

(Line 19 – Line 14)

VI. “Write-Ins” Reconciliation Items (provide short description below)

21. _____________________________________________________________

22. _____________________________________________________________

23. _____________________________________________________________

24. _____________________________________________________________

25. _____________________________________________________________

26. Subtotal (Lines 21 through 25)

____________

VII. Remaining Variance

27. Imbalance (Line 26 – Line 20)

____________

3

Prior to May 1, 2003 the per claim deductible for a large deductible policy had to be at least $100,000. Effective May 1, 2003, the minimum per

claim deductible for a large deductible policy was reduced to $75,000.

Page 3 of 3

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section IV

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting Page 5:1

CALL #5 RESIDUAL MARKET DIRECT WRITTEN PREMIUM

Data Period: Calendar Year data

Due Date: April 1

A. Description

Report the calendar year direct written premium, consistent with the reporting on the Exhibit of

Premiums and Losses of the Annual Statement (Statutory Page 14), by policy year for residual

market policies.

B. Reporting Requirements

1. For each of the five most recent policy years, report the policy year contribution to the calendar year

direct written premium for residual market policies.

2. The remaining calendar year direct written premium for residual market policies should be reported

in the prior year line (Line A).

3. Terrorism Insurance Program (Certified Acts of Terrorism) Premium should be included,

consistent with the reporting of direct premium on the Annual Statement.

C. Column Instructions

Column 1: Residual Market (including “F” Classification and Maritime experience) Direct Written

Premium

Massachusetts workers’ compensation and employer’s liability direct written premiums

as reported on Column 1, Line 16 Statutory Page 14 of the Annual Statement for

residual market policies (i.e., voluntary direct assigned risk policies and servicing

carrier policies).

Column 2: VDAR (including “F” Classification and Maritime experience) Direct Written Premium

Massachusetts workers’ compensation and employer’s liability direct written premiums

as reported on Column 1, Line 16 Statutory Page 14 of the Annual Statement for

voluntary direct assigned risk policies. This item refers only to VDAR policy premium. It

does not refer to assigned risk premium from policies serviced by servicing carriers.

Call # 5 – RESIDUAL MARKET DIRECT WRITTEN PREMIUM

(1)

(2)

Line

Calendar

Year

Policy

Year

Residual Market

(including “F”

Classification and

Maritime experience)

VDAR

(including

“F” Classification and

Maritime experience)

A.

XXXX

Prior to

XXXX - 4

B.

XXXX XXXX - 4

C.

XXXX XXXX - 3

D.

XXXX XXXX - 2

E.

XXXX XXXX - 1

F.

XXXX XXXX

G.

Total

Page 1 of 1

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section IV

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting Page 5A:1

CALL #5A – LARGE DEDUCTIBLE COMPANY LEVEL WRITTEN PREMIUM

Data Period: Calendar Year data

Due Date: April 1

A. Description

For large deductible policies, report the current calendar year written standard premium at company

level and the ARAP surcharge.

B. Reporting Requirements

1. Data is to be reported for all large deductible policies effective on or after January 1, 1994.

2. Consistent with the Policy Year Large Deductible Calls, Terrorism Insurance Program (Certified

Acts of Terrorism) Premium should not be included.

3. Unlike the Policy Year Large Deductible Call, do not exclude written premiums associated with

“F” Classification and Maritime experience.

C. Column Instructions

Column 1: Large Deductible

1

Written Standard Premium at Company Level

The Large Deductible Written Standard Premium at Company Level is analogous to the

earned Standard at Company Level premium reported on Call # 2C – Policy Year

Large Deductible Call except that this call is asking for written premium instead of

earned premium and includes written premiums associated with “F” Classification and

Maritime experience.

Column 2: Large Deductible

4

Written ARAP Premium Surcharge

The Large Deductible Written ARAP Premium Surcharge is analogous to the earned

ARAP premiums reported on Call # 2C – Policy Year Large Deductible Call except that

this call is asking for written premium instead of earned premium and includes written

premiums associated with “F” Classification and Maritime experience.

4

Prior to May 1, 2003 the per claim deductible for a large deductible policy had to be at least $100,000. Effective May

1, 2003, the minimum per claim deductible for a large deductible policy was reduced to $75,000.

Call # 5A – LARGE DEDUCTIBLE COMPANY LEVEL WRITTEN PREMIUM

(1) (2)

Calendar

Year

Large Deductible Company Level Written Premium

Standard Premium

ARAP Premium

XXXX

Page 1 of 1

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013 Section IV

Distributed: August, 2013 ANNUAL CALLS

Part II – Aggregate Financial Reporting Page 5B:1

CALL #5B – DIRECT WRITTEN PREMIUM

Data Period: Calendar Year data

Due Date: April 1

A. Description

This written premium report records the calendar year workers’ compensation direct written premiums

for certain market segments. The most recent calendar year data through December 31 should be

reported.

B. Reporting Requirements

1. For purposes of reporting USL&HW written premium, include “F” Classification codes and Non “F”

Classification codes that have been modified by the USL&HW premium multiplier.

2. The Total calculated in column (4) must reconcile to the direct written premium reported on the

Exhibit of Premiums and Losses of the Annual Statement (Statutory Page 14).

3. Terrorism Insurance Program (Certified Acts of Terrorism) Premium should be included,

consistent with the reporting of direct premium on the Annual Statement.

4. Include premiums associated with Maritime experience.

C. Column Instructions

Column 1: Direct Written Premium

Report all premiums written in a manner consistent with the amounts reported in Line

16 of the Exhibit of Premiums and Losses of the Annual Statement (Statutory Page 14),

excluding all premiums for U.S. Longshore and Harborworkers’ Act (USL&HW), and

National Defense Plans.

Column 2: USL&HW Premium

Report all premiums written under the U.S. Longshore and Harborworkers’ Act

(USL&HW), in a manner consistent with the amounts reported in Line 16 of the Exhibit

of Premiums and Losses of the Annual Statement (Statutory Page 14).

Column 3: National Defense Plan Premium

Report all premiums written under special National Defense Comprehensive Rating or

specific National Defense Premium Discount plans, in a manner consistent with the

amounts reported in Line 16 of the Exhibit of Premiums and Losses of the Annual

Statement (Statutory Page 14).

Column 4: The sum of Columns (1) through (3)

Column 5: Large Deductible Direct Written Premium

Massachusetts workers’ compensation and employer’s liability direct written premiums

as reported in Line 16 of the Exhibit of Premiums and Losses of the Annual Statement

(Statutory Page 14) for large deductible policies including written premiums associated

with “F” Classification and Maritime experience. Only report premiums for policies

effective on or after January 1, 1994.

CALL #5B – DIRECT WRITTEN PREMIUM

(1)

(2)

(3)

(4)

(5)

Calendar

Year

Direct Written Premium

All Premium

USL&HW

Premium

National

Defense

Plan

Premium

Total of Columns

(1) – (3)

Reconcilable to

Exhibit of

Premiums and

Losses

Large

Deductible

XXXX

Page 1 of 1

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STATISTICAL PLAN

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Part II – Aggregate Financial Reporting Page 6:1

CALL #6: MASSACHUSETTS CALENDAR YEAR EXPENSE DATA

Data Period: Calendar Year data

Due Date: May 15

A. Description

Report the expenses associated with writing workers’ compensation coverage in Massachusetts.

B. General Instructions

1. Adjusting and Other (AO) Expenses should be reported in accordance with the current NAIC

definitions.

2. Expenses are reported on a calendar year basis.

3. Do not report expense amounts paid as penalties or fees in accordance with Sections 7, 8, 10,

13A, and 14 of Chapter 152 of the General Laws of Massachusetts

.

4. Do not subtract from the expense totals any fees received for servicing policies for a third party

including servicing carrier fees.

5. Expense values are for all workers’ compensation business, including “F” Classification experience,

Large Deductible, Maritime experience as well as National Defense experience.

C. Row Instructions

Row 1: Other Acquisitions, Field Supervision, and Collection Expenses Incurred. Commission and

Brokerage Expenses should be excluded.

Row 2: Adjusting and Other Expenses.

Row 3: General Expenses. Note that this should include the Boards and Bureau Expenses which

are also reported separately.

Row 3A: Boards and Bureau Expenses.

Row 4: Incidental Income. A positive value indicates income for the calendar year.

Row 5: Unreported Expenses. A positive value indicates an expense for the calendar year.

Row 6: Uncollectible Premium Receivables. A positive value indicates an expense for the calendar

year.

Call # 6 – MASSACHUSETTS C A L E N D A R Y E A R E X P E N S E D A T A

Expense Category Incurred

(1)

Other Acquisitions, Field Supervision and Collection Expenses

(2)

Adjusting and Other Expenses

(3)

General Expenses

(3A)

Boards and Bureau Expenses

(4)

Incidental Income

(5)

Unreported Expenses

(6)

Uncollectible Premium Receivables

Page 1 of 1

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Part II – Aggregate Financial Reporting Page 6A:1

CALL #6A: INSURANCE EXPENSE EXHIBIT

Data Period: Calendar Year data

Due Date: April 15

A. Description

Report a copy of the Insurance Expense Exhibit (IEE) which provides countrywide expense

information.

B. General Instructions

1. You are not required to submit the Insurance Expense Exhibit (IEE) to WCRIBMA if your

company has already submitted it to the National Association of Insurance Commissioners

(NAIC).

2. If your company does not submit its IEE to the NAIC, you must send a pdf copy via MAFDRA to

WCRIBMA.

3. Please submit your IEE on an individual company basis rather than a group basis.

MASSACHUSETTS WORKERS’ COMPENSATION

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Part II – Aggregate Financial Reporting Page 7:1

CALL # 7: LARGE LOSS & CATASTROPHE CALL

Data Period: Claims valued as of December 31

Due Date: April 15

A. Description

• Report all claims for accident year 1984 and later where total case incurred losses are greater

than or equal to $500,000 at the time of valuation.

• Report all extraordinary loss event claims regardless of size, including medical-only claims. The

WCRIBMA will notify member companies of any new event that has been classified as an

extraordinary loss event. Refer to Appendix I – Extraordinary Loss Event Table

for a list of

extraordinary loss event catastrophe numbers.

B. General Instructions

1. The data reported in this Call should exclude the following experience:

• Excess Workers’ Compensation

• National Defense Projects Rating Plan

2. Report claims individually. Claims cannot be grouped.

3. Closed, as well as open and reopened claims are included.

4. Loss amounts should be reported net of second injury fund reimbursements and other recoveries

such as subrogation, but gross of deductible reimbursements, consistent with the Policy and

Accident Year Calls.

5. Case Outstanding may include or exclude statutorily allowable discounting, as long as the

approach is consistent with the Policy and Accident Year Calls.

6. Unlike extraordinary loss event claims, if the case incurred for a large loss claim previously

reported on this call drops below $500,000, do not report the claim.

C. Column Instructions

Column 1: Claim Number - A unique number assigned by the insurance company to a claim for

the life of that claim. Claim numbers must be reported in a manner consistent with unit

statistical reporting.

Column 2: NCCI Carrier Code - A unique 5 digit numeric code assigned by the National Council

on Compensation Insurance (NCCI) to an insurance company.

Column 3: Policy Number – Policy number associated with the claim. Policy Numbers must be

reported in a manner consistent with unit statistical reporting.

Column 4: Catastrophe Number – Report catastrophe code for all extraordinary loss events

assigned a unique catastrophe number (for example, report 48 for all Catastrophe

Number 48 claims, regardless of claim size). Catastrophe numbers must be reported

in a manner consistent with unit statistical reporting.

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Part II – Aggregate Financial Reporting Page 7:2

Column 5: Policy Effective Date – The inception date of the policy associated with the claim.

Policy effective date must be reported in a manner consistent with unit statistical

reporting.

Column 6: Accident Date – The date on which the large loss or catastrophe occurred. Accident

date must be reported in a manner consistent with unit statistical reporting.

Column 7: Loss Condition Act Code – A code that identifies the basis of liability for the claim.

01 – State Act or Federal Excluding USL&HW

02 – USL&HW

Loss condition act code must be reported in a manner consistent with unit statistical

reporting.

Column 8: Accumulated Paid Indemnity

Column 9: Accumulated Paid Medical

Column 10: Case Reserves Indemnity

Column 11: Case Reserves Medical

Column 12: Accumulated Defense and Cost Containment Expense – Paid

Column 13: Defense and Cost Containment Expense – Case Reserves

CALL # 7: LARGE LOSS & CATASTROPHE CALL

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

(13)

Accumulated Paid Losses Case Reserves

Defense and Cost

Containment Expense

Claim

Number

NCCI

Carrier

Code

Policy

Number

Catastrophe

Number

Policy

Effective

Date

Accident

Date

Loss

Condition

Act Code

Indemnity Medical Indemnity Medical

Accumulated

Paid

Case

Reserves

Page 1 of 1

PART III

DEFINITIONS

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STATISTICAL PLAN

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Distributed: August, 2013

PART III - DEFINITIONS Page 1

PART III – DEFINITIONS

A. Premiums Reported in Statistical Plan

Part A of the definitions is organized into the following components:

• General Premium Information

• Premiums reported in Aggregate Financial Call

• Aggregate Financial Premium Levels

• Unit Statistical Reporting Premium Levels

• Premium Component Table

1. General Premium Information

The following should not be reflected on any of the aggregate financial calls or unit statistical reports

data:

• Assumed reinsurance premiums

• Ceded reinsurance premiums

• Excess workers’ compensation

• National Defense plans

• Atomic Energy Project Work

Report all premiums whether collected or not (consistent with Statutory Accounting Principles).

2. Premiums Reported in Aggregate Financial Calls

a. Policy Year Premium and Calendar Year Premium

Policy year premium is the premium associated with policies that have policy effective dates during

a specific calendar year. Policy year premium can change from valuation to valuation as premium

audits are performed or retrospective premium adjustments are made.

Calendar year premium is the aggregate total of the premiums recorded on the company books

during a given calendar year, regardless of the policy effective date. Calendar year premium is fixed

at the end of the calendar year, and is not subject to change from valuation to valuation.

b. Written and Earned Premium

Written premium is the estimated premium for the entire policy term including any estimates of

premium audits and retrospective rating premium adjustments.

Statutory accounting allows for workers’ compensation written premiums to be recorded using one of

two methods.

• Written premiums may be recorded on an installment basis to match the billing to the

policyholder.

• Written premiums may be recorded as of the effective date of the contract.

Written premium reported on the Aggregate Financial calls must be recorded using the same

method for recognizing written premiums employed in preparing the Annual Statement.

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PART III - DEFINITIONS Page 2

Written premium does not include advance premiums received by the insurance company for

policies yet to take effect.

Earned premium is the proportional share of the written premium applicable to the expired portion

of the policy.

Earned premium reported on the aggregate financial calls must be recorded using the same

method for prorating written premiums as was employed in preparing the Annual Statement.

3. Aggregate Financial Premium Levels

Four distinct levels of premium are submitted in Part II of the Statistical Plan. The difference between

levels is associated with the inclusion or exclusion of various credits and company specific rating

mechanisms such as deviations and schedule rating. The most frequently utilized components of each

premium type are illustrated in the premium component table, and further defined in the listing that

follows.

a. Standard Premium at Bureau Designated Statistical Reporting (DSR) Level

Standard Premium at DSR Level is the premium resulting from standard rating procedures as if all

policies had been issued using WCRIBMA manual rates.

b. Standard Premium at Company Level

Standard Premium at Company Level is the premium calculated by adjusting the Standard Earned

Premium at DSR level by application of any company deviation.

c. Net Premium Level

Net Premium is the premium calculated by adjusting the Standard Premium at Company level for all

schedule rating credits, premium discounts, deductible premium credits, and retrospective rating

premium adjustments.

d. Direct Premium (Direct Premium at Annual Statement Basis) Level

Direct premiums are the aggregate amount of recorded originated premiums, excluding all

reinsurance assumed without deducting any reinsurance ceded, whether collected or not, at the

close of the year (plus retrospective premium collections), after deducting all return premiums. In

financial statements, it is the premium income adjusted for additional or return premiums but

excluding any additions for reinsurance assumed and any deductions for reinsurance ceded.

Direct premiums are calculated by adjusting the Net Premium for ARAP, QLMP

Credit and Terrorism Insurance Program.

4. Unit Statistical Reporting Premium Levels

a. Premium Amount

The premium amount for a class is either developed by multiplying units of exposure times the

manual rate or it’s the premium assigned to a statistical class code. Refer to Part I,

Section V –

Exposure Record Data Subsection C.6.

b. Subject Premium

Refer to the Massachusetts Premium Algorithm

.

c. Modified Premium

Refer to the Massachusetts Premium Algorithm

.

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PART III - DEFINITIONS Page 3

d. Standard Premium

Refer to the Massachusetts Premium Algorithm

.

5. Premium Components Table

The components of each premium type are summarized in the following table (an “x” denotes that the

component is included in the column):

Premium Components

Components

Aggregate Financial Premium Levels

Unit

Statistical

Report

Premium

Class

Codes

Standard

Premium

at Bureau

Designated

Statistical

Rate Level

Standard

Premium

at Company

Level

Net

Premium

Direct

Premium

1. Manual Premium

Class Categories:

a. Manual Class Code x x x x x

Too many

to list

b. Supplemental Disease x x x x x

0059, 0065,

0066, 0067

c. Non –Ratable x x x x x

0771, 7445,

7453

d. Supplemental Atomic Energy

Exposure

x x x x x 9985

2. Rate Deviations x x x x 9037, 9034

3. Scheduled Rating Adjustments x x x 9887, 0887

4. Waiver of Subrogation x x x x x 0930

5. Employers Liability Increased

Limits

x x x x x

9803-9816,

9848

6. Experience Rating x x x x x NA

7. Merit Rating x x x x x 9884-9886

8. MA CCPAP x x x x x 9046

9. ARAP Surcharge x x 0277

10. Massachusetts Benefits

Deductible Premium Credit

x x x 9664

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PART III - DEFINITIONS Page 4

Premium Components

Components

Aggregate Financial Premium Levels

Unit

Statistical

Report

Premium

Class

Codes

Standard

Premium

at Bureau

Designated

Statistical

Rate Level

Standard

Premium

at Company

Level

Net

Premium

Direct

Premium

11. Massachusetts Benefits Claim

and Aggregate Deductible

Premium Credit

x x x 9664

12. Large Deductible Premium

Credit

x x x 9663,9664

13. Premium Discount x x x 0063, 0064

14. QLMP Credit x x 9880

15. Balance to Admiralty / FELA

Minimum Premium

x x x x x 9849

16. Loss Constant x x x x x 0032

17. Expense Constant x x x x x 0900

18. Balance to Total Policy Minimum

Premium Adjustments

x x x x x 0990

19. Terrorism Insurance Program

Premiums

x x 9740

20. Short Rate Penalty Premium x x x x x 0931

21. Retrospective Rating

Adjustments

x x NA

22. Special Circumstances:

a. Independently Filed Carrier

Program

x x x 9721 – 9724

b. Formerly Self Insureds x x x 9129, 9136

c. No-Massachusetts Exposure Must be zero 1111

23. Deductible Reimbursements Do Not Report

24. Policyholder Dividends Do Not Report

25. DIA Assessment Do Not Report

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PART III - DEFINITIONS Page 5

1. Manual Premium – Class Categories:

a. Manual Class Code

For definition and for a list of all classifications refer to

Massachusetts Workers Compensation and

Employers Liability Insurance Manual.

b. Supplemental Disease

The premium for supplementary disease rates and any resulting losses are reported as follows:

Code

Description

0059 Occupational Disease-Abrasive/Sand Blast

0065 Occupational Disease-Steel

0066 Occupational Disease-Non-Ferrous Metals

0067 Occupational Disease-Iron

For more information refer to the

Massachusetts Workers Compensation and Employers Liability

Insurance Manual.

c. Non-Ratable

Some classifications have a non-ratable element that is not subject to experience rating and is reported

using the statistical class codes from the table below. Non-ratable element class codes must only be

reported in conjunction with the corresponding basic classification ratable classes. The payroll for each

of the paired classes must be equal.

Non-Ratable

Element

Basic

Classification

Description

0771 4771 Explosives or Ammunition; NOC and Drivers

7445 7405 Air Carrier-Other Flying Crew

7453 7431 Air Carrier, Commuter Flying Crew

For more information refer to the

Massachusetts Workers Compensation and Employers Liability

Insurance Manual.

d. Supplemental Atomic Energy Exposure

Use code 9985 to report any exposure and premium associated with supplemental atomic energy

exposure.

For more information refer to the

Massachusetts Workers Compensation and Employers Liability

Insurance Manual.

2. Rate Deviations

Insurance companies may independently file for rate deviations. In Massachusetts, rate deviations are only

allowed to adjust premiums downward.

Individual insurance companies must get approval from the Massachusetts Division of Insurance prior to

applying rate deviation to the WCRIBMA’s approved rates. The WCRIBMA does not file a rate deviation

MASSACHUSETTS WORKERS’ COMPENSATION

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PART III - DEFINITIONS Page 6

plan on behalf of its members. See the Massachusetts Division of Insurance website for rate deviations

guidelines.

Use code 9037 to report rate deviations that are applied before the experience rating modification, i.e.,

calculated prior to the application of the experience modification.

Use code 9034 to report rate deviations that were applied after the experience rating modification, i.e.,

calculated after the application of the experience modification. Carrier filed programs for rate deviations that

are applied after the experience rating modification expired with rate changes effective 9/1/08.

3. Schedule Rating Adjustments

Insurance companies may independently file a schedule rating plan that allows the insurance company to

modify an insured’s premium based on the special characteristics of risk that are not reflected in the

experience. In Massachusetts, schedule rating programs are only allowed to adjust premiums downward.

Downward schedule rating adjustments are known as schedule rating credits.

Individual insurance companies must get approval from the Massachusetts Division of Insurance prior to

offering schedule rating to their insureds. The WCRIBMA does not file a schedule rating plan on behalf of its

members. See the Massachusetts Division of Insurance website for scheduling rating guidelines.

Premium adjustment associated with scheduled rating plans that are subject to experience rating, i.e.,

calculated before the application of the experience modification, are to be reported with code 0887.

Premium credits associated with scheduled rating plans that were not subject to experience rating, i.e.,

calculated after the application of the experience modification, are to be reported with class code 9887.

Carrier filed scheduled rating plans applied after experience rating modification expired with rate changes

effective 9/1/08.

4. Waiver of Subrogation

When a policy is endorsed to waive the right to subrogate, the carrier cannot pursue subrogation recoveries

from a third party. Waiver of subrogation, reported with code 0930, may apply to a policy in total or to a

specific job covered by the policy.

5. Employers Liability Increased Limits

If an insured selects limits higher than the standard limits for employer’s liability a premium charge subject to

a minimum is applied. Any additional premium required to reach the minimum employers liability premium

should be coded as 9848.

The premium charge for increased employer’s liability limits is reported with the code assigned to the

selected limits.

Code

Employer’s Liability Increased Limits

($000 omitted)

Per Accident

Each

accident

Per Disease

Each

Employee

Per Disease

Each Policy

9803

100 100 1,000

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PART III - DEFINITIONS Page 7

Code

Employer’s Liability Increased Limits

($000 omitted)

Per Accident

Each

accident

Per Disease

Each

Employee

Per Disease

Each Policy

9804 100 100 2,500

9805

100

5,000

9806

100

10,000

9807 500 500 500

9808

500

1,000

9809 500 500 2,500

9810

500

5,000

9811

500

10,000

9812 1,000 1000 1,000

9813

1,000

1000

2,500

9814 1,000 1000 5,000

9815

1,000

1000

10,000

9816 *See Note

9848

Increased Limits, additional premium to

balance to minimum premium.

* Note: Statistical class code 9816 will cover all limits not otherwise defined.

For more information refer to the

Massachusetts Workers Compensation and Employers Liability Insurance

Manual.

6. Experience Rating

Refer to the Experience Rating Plan Manual

.

7. Merit Rating

For merit rated risks, report the code that describes the premium impact of merit rating. For a merit rated

risk, Code 9884 indicates that neither a merit rating credit nor a merit rating debit applied.

Code

Description

9884

Unity

9885

Credit

9886

Debit

For more information refer to the Experience Rating Plan Manual

.

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8. Massachusetts Construction Classification Premium Adjustment Program (MA CCPAP)

Use code 9046 to report MA CCPAP.

For more information refer to the

Massachusetts Workers Compensation and Employers Liability Insurance

Manual.

9. All Risk Adjustment Program (ARAP) Surcharge

Use Code 0277 to report ARAP.

For more information refer to the Experience Rating Plan Manual

.

10. Massachusetts Benefits Deductible Premium Credit (Small Deductible)

Premium credits associated with the Massachusetts Benefits Deductible Program are to be reported with

class code 9664. The per claim deductible amount is to be reported in the header record in the claim

deductible amount. Losses subject to deductible code is 03 and basis of deductible calculation code

is 01.

For more information refer to the

Massachusetts Workers Compensation and Employers Liability Insurance

Manual.

11. Massachusetts Benefits Claim and Aggregate Deductible Premium Credit (Small Deductible)

Premium credits associated with the Massachusetts Benefits Claim and Aggregate Deductible Program are

to be reported with class code 9664. The per claim/accident deductible amount and the aggregate

deductible are to be reported in the header record in the claim deductible amount.

Losses subject to

deductible code is 03 and basis of deductible calculation code is 01.

For more information refer to the

Massachusetts Workers Compensation and Employers Liability Insurance

Manual.

12. Large Deductible Premium Credit

Individual insurance companies must get approval from the Massachusetts Division of Insurance for

permission to write large deductible policies. See the Massachusetts Division of Insurance website for

requirements applicable to Workers’ Compensation deductible policies (211 CMR 115.00

).

Large deductible credits that apply after the application of the experience modification, are reported with the

statistical class code 9663.

Large deductible credits that apply before the application of the experience modification, are reported with

the statistical class code 9664.

13. Premium Discount

Code Description

0063 Type A

0064

Type B

For more information refer to the

Massachusetts Workers Compensation and Employers Liability Insurance

Manual.

14. QLMP Credit

Use statistical class code 9880 to report QLMP credit.

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PART III - DEFINITIONS Page 9

For more information refer to the Massachusetts Workers Compensation and Employers Liability Insurance

Manual.

15. Balance to Admiralty / FELA Minimum Premium

Determine the balance to Admiralty / FELA minimum premium in accordance with Massachusetts Premium

Algorithm and report using statistical class code 9849.

16. Loss Constant

Use statistical class code 0032 to report loss constant premium.

For more information refer to the

Massachusetts Workers Compensation and Employers Liability Insurance

Manual.

17. Expense Constant

Use statistical class code 0900 to report expense constant premium, including the balance to minimum

expense constant.

For more information refer to the

Massachusetts Workers Compensation and Employers Liability Insurance

Manual.

18. Balance to Total Policy Minimum Premium Adjustments

Determine the balance to total policy minimum premium in accordance with Massachusetts Premium

Algorithm and report using statistical class code 0990.

The following must be reported separately, because they are calculated prior to calculation of balance to

total policy minimum, and therefore not included in premium amount reported with statistical class code

0990:

• expense constant

• loss constant

• employer’s liability premium

• admiralty and/or FELA policy premium

For more information refer to the Massachusetts Premium Algorithm

.

19. Terrorism Insurance Program (Certified Acts of Terrorism) Premiums

Report the Terrorism Insurance Program (Certified Acts of Terrorism) premiums with statistical class code

9740.

For more information refer to the

Massachusetts Workers Compensation and Employers Liability Insurance

Manual.

20. Short Rate Penalty Premium

Report any short rate penalty premium with statistical class code 0931.

For more information refer to the

Massachusetts Workers Compensation and Employers Liability Insurance

Manual.

21. Retrospective Rating Adjustments

The retrospective rating plan is an optional rating plan approved by the Massachusetts Division of Insurance

for larger insureds.

For more information refer to the Retrospective Rating Plan Manual

.

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PART III - DEFINITIONS Page 10

22. Special Circumstances:

a. Independently filed Carrier Program Premium Adjustments

Four statistical class codes have been established for independent carrier filings of credit/debit

programs.

Code

Description

9721

Carrier filed premium credit subject to experience rating

9722

Carrier filed premium credit not subject to experience rating

9723

Carrier filed premium debit subject to experience rating

9724

Carrier filed premium debit not subject to experience rating

Before reporting any of the independent carrier filing codes, notification of the program must be provided

to the WCRIBMA’s Data Operations Department.

The statistical classes listed above for independently filed carrier programs are never to be used to

report premium credits due to independently filed large deductible programs or scheduled rating

programs. See definitions of large deductible programs and scheduled rating programs.

b. Formerly Self-Insureds

The formerly self-insured insurance charge is to be reported with statistical class code 9136.

The formerly self-insured rating plan deposit is reported with statistical class code 9129. If any of the

deposit is returned to the insured, then a correction to the first unit statistical report must be submitted

adjusting the rating plan deposit to the amount retained by the carrier. This adjustment can be made no

sooner than thirty (30) months after the coverage expiration date. All claims must be closed and all

incurred losses finalized prior to the submission of the adjustment.

For more information refer to the Circular Letter Number 1524

, dated February 7, 1990.

c. No-Massachusetts Exposure

When a policy is issued either on an “if any” basis, or as a multi-state policy, and upon audit it is

determined that Massachusetts exposure did not develop on such policy, the first unit statistical report

should be submitted with a single exposure record employing statistical class code 1111.

23. Deductible Reimbursements

Do not report deductible reimbursements as premiums.

In Massachusetts workers’ compensation insurance, the insurance company is required to pay for all claims

including those below any applicable deductible, large or small. If a deductible applies to a given policy, the

insurance company will seek reimbursement from the insured for amounts below the deductible.

24. Policyholder Dividends

Do not report policyholder dividends as premiums.

Any amounts paid or credited to policyholders that are not fixed in the insurance contract but are dependent

on either the experience of the insurance company or employer or the discretion of the insurance company

management.

25. DIA Assessment

Do not report DIA assessment as premiums.

For more information, visit the DIA website at: www.mass.gov/dia

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PART III - DEFINITIONS Page 11

B. Losses and Loss Adjustment Expenses (LAE) Reported in Statistical Plan

Part B of the definitions is organized into the following components:

• General Loss Information

• Summarizing Losses When Reporting on the Aggregate Financial Calls

• Indemnity Losses

• Medical Losses

• Paid Losses

• Case Reserves

• Reserve Discounting

• Incurred But Not Reported (IBNR) Reserves

• Case Incurred

1. General Loss Information

• No assumed reinsurance losses or ceded reinsurance losses should be reflected on any of the

aggregate financial calls and unit statistical reporting data.

• Direct losses are first-dollar losses less deductible reimbursements. Deductible reimbursements are the

amounts actually reimbursed by the insured plus any amounts expected to be reimbursed by the

insured. With the exception of the incurred loss value from Statutory Page 14 used to complete the

Reconciliation Report (Call #4), all loss amounts are to be reported before any offsets for deductibles.

Likewise, all loss adjustment expense amounts are to be reported before any offsets for deductibles.

• Do not classify a claim as Massachusetts if the jurisdiction state is Massachusetts but the associated

exposures used to calculate the policy’s premium are for a state other than Massachusetts.

Conversely, if the jurisdiction state is not Massachusetts but the associated exposures used to calculate

the policy’s premium are for Massachusetts, classify such a claim as Massachusetts.

• Lump Sum Settlements

Where a claim involves a lump sum settlement which represents a commuted value of a specific award

or benefit, report the actual loss payment subdivided into its indemnity and medical components. In

instances where this cannot be readily determined, report amounts which the carrier believes to be the

most likely breakdown.

• Subrogation

Subrogation recovery is a recovery of losses by the carrier from an entity, other than the employer, with

legal liability due to circumstances of the injury. For data reporting purposes, a subrogation recovery is

deemed to be successful if the recovery amount exceeds the costs associated with pursuing the

subrogation recovery (recovery expenses).

If subrogation is successful, calculate loss amounts net of subrogation (net loss) as follows:

Net Loss = Gross Loss – (Subrogation – Recovery Expense)

Such net loss must be allocated to medical and indemnity. If there is insufficient information regarding

the subrogation recovery to make specific allocations, the net loss must be divided between indemnity

and medical losses in the same proportion as the gross indemnity and medical loss amounts.

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If subrogation is unsuccessful, meaning subrogation recovery does not exceed the expense associated

with pursuing recovery, report gross loss.

• Reimbursement from a Special Fund such as a Second Injury Fund

In all cases where reimbursement is made to the carrier from a special fund (such as a Second Injury

Fund), report loss net of the special fund reimbursement (net loss) as follows:

Net Loss = Gross Loss – Special Fund Reimbursement

Such net loss must be allocated to medical and indemnity. If there is insufficient information regarding

the special fund reimbursement to make specific allocations, the net loss must be divided between

indemnity and medical losses in the same proportion as the gross indemnity and medical amounts.

2. Summarizing Losses When Reporting the Aggregate Financial Calls

• Accident Year , Policy Year and Calendar Year Losses and Loss Adjustment Expenses

Accident year losses and loss adjustment expenses are the inception to date total dollar amounts

associated with all claims having an accident date in a given year, regardless of when the loss and/or

claim is reported or the policy is effective.

Note that accident year losses and loss adjustment expense are subject to change over time as losses

develop and/or additional claims are reported.

Policy year losses and loss adjustment expenses are the inception to date dollar amounts that

arise for a group of policies having policy effective dates in a given year, regardless of when the loss

and/or claim is reported.

Note that policy year losses and loss adjustment expense are subject to change over time as losses

develop and/or additional claims are reported.

In order to maintain consistency with the ASWG Unit Report Workers’ Compensation Statistical Plan

reporting requirements, policies with terms greater than one year and 16 days and effective dates on or

after January 1, 2009 must be segmented in the same manner as was done for purposes of unit

statistical reporting. The beginning date for each segment shall be used for determining the policy year.

Calendar year loss and loss adjustment expenses are the year to date total dollar amounts

associated with all claims regardless of the accident date, the policy effective date, or date the loss is

reported.

Note that calendar year losses and loss adjustment expenses are not subject to change beyond

December 31 because they are year to date summaries.

3. Indemnity Losses

Definition of indemnity losses apply to both aggregate financial and unit statistical reporting unless stated

otherwise.

Indemnity losses are losses associated with:

a. wage compensation

b. burial expenses

c. sums designated for specific injuries or disfigurements

d. claimants’ attorney fees

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e. vocational rehabilitation

f. employer’s liability losses and employer’s liability expenses

g. survivor benefits

 Expenses Included in Indemnity Losses

• Employer’s Liability Losses

Employer’s Liability losses including Allocated Loss Adjustment Expenses (ALAE) must be reported

as part of the indemnity loss as appropriate. Employer’s Liability ALAE represents the expenses of

a carrier in connection with claim settlements, which can be directly allocated to a particular claim.

Employer’s Liability ALAE should not be reported in the ALAE amount.

• Impartial Medical Examinations by Industrial Board

Filing fees paid by the carrier to fund impartial medical examinations pursuant to Section 11A of

Chapter 152 of the Massachusetts General Laws

are to be considered:

o An expense when the carrier prevails or

o A loss when the claimant prevails and the carrier reimburses the claimant’s filing fees.

• Awards

When an award to a claimant includes the cost of witness fees, attorneys’ fees, and other court

costs or expert medical witness fees, the amount so awarded shall be considered as part of the

cost of benefit and shall be included with the indemnity reported. Such costs include those incurred

under Section 11A, 11B, 12A and 39 of Chapter 152, Massachusetts General Laws

.

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

recovery is made against the third party by the employee.

• Vocational Rehabilitation

Vocational rehabilitation is concerned with the prospect of returning an injured worker to gainful

employment. Vocational rehabilitation concerns all activities performed when acquiring

reemployment of a disabled person, such as evaluation, testing, training, job placement, schooling,

job modification, and part-time employment.

Outside Vendor:

Vocational rehabilitation costs, including evaluation and testing, incurred due to the purchase of

vocational rehabilitation services from outside vendors, must be reported as part of indemnity

losses. “Evaluation and testing expenses” are defined as costs incurred in testing and evaluating

the claimant’s ability, aptitude, or attitude in determining suitability for vocational rehabilitation or

placement.

Carrier Personnel:

Vocational rehabilitation expenses for evaluation and testing resulting from the activities of carrier

personnel (other than claims supervisors or claims adjusters engaged in efforts to return an injured

worker to gainful employment) may be reported as indemnity incurred loss if carrier personnel

engaged in these activities meet, at a minimum, qualifications established by the state having

jurisdiction over the particular claim.

The cost of schooling is a vocational rehabilitation cost and is reported as part of the indemnity loss

as appropriate. For example, a laborer who is found to have a permanent total disability preventing

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him or her from being able to return to previous employment is sent to school to learn accounting in

order to attain a job in the accounting profession.

• Legal Expenses Incurred for the Benefit of the Claimant

Legal court expenses incurred for the benefit of the claimant shall be reported as either an

indemnity or medical loss depending upon the nature of the expense.

• Penalties for Delays in Making Compensation Payments

Penalties for which the carrier is liable for reasons beyond its control and that accrue as benefits

to the injured worker or his or her dependents, such as for interest on awards or for penalties

imposed upon the employer for improper controversies of awards, shall be chargeable to indemnity

losses and so reported.

Penalties for which the carrier is liable for reasons within its control specifically penalties for which

the carrier is liable pursuant to Sections 7(2), 8(1), 10(5), 13A (1), and 14(1) of Chapter 152 of the

Massachusetts General Laws

shall not be reported as a loss or charged to expense.

 Expenses Excluded from Indemnity Losses

• Unit Statistical Reporting

o Allocated Loss Adjustment Expense (ALAE)

See definition of allocated loss adjustment expense

in Section D.

Note: This exclusion does not apply to employer’s liability claims.

o Unallocated Loss Adjustment Expense (ULAE)

Unallocated Loss Adjustment Expense (ULAE) is also excluded from losses.

See definition of unallocated loss adjustment expense

in Section D.

• Aggregate Financial

o Defense and Cost Containment (DCC)

See definition of defense and cost containment

in Section D.

o Adjusting and Other (AO)

See definition of adjusting and other

in Section D.

4. Medical Losses

Medical losses encompass the following health care services:

a. Physicians care for home, office or hospital visits.

b. Other health care providers for home, office or hospital visits.

c. Diagnostic tests and procedures.

d. Hospital or skilled nursing facility charges for service and supplies including room and board.

e. Medical, occupational, surgical or other health related supplies and devices, services, training, therapy,

or procedures.

f. Prescribed Drugs and Medicine.

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g. Mental Health Care.

h. Medically necessary Transportation Services.

i. Prosthetic Services and Devices.

j. Medical examinations to diagnose the injury and determine the proper treatment including specialist’s

opinion and second opinions.

k. Medical Testimony: Where the claimant calls in the attending physician to give medical testimony in his

behalf, or where the carrier is required to produce the claimant’s physician at the hearing and the

employer or the insurance carrier is required to pay such physician’s fee, the payment of the fee shall

be reported as a medical loss. Such costs include those incurred under Section 9A of Chapter 152 of

Massachusetts General Laws

.

l. Physical Rehabilitation

i. Outside Vendors

Physical rehabilitation costs incurred due to the purchase of physical rehabilitation services from

outside vendors must be reported as part of the medical loss.

ii. Carrier personnel

Expenses incurred by the carrier for the physical rehabilitation activities listed below may be

included in losses if performed by carrier personnel (other than claims supervisor and claims

adjusters engaged in efforts to return an injured worker to gainful employment) that are trained in

health care services:

• Various necessary evaluations and therapies including physical, occupational, speech, and

hearing.

• Coordination of services such as necessary medical equipment or special nursing care in a

facility or the home.

• Necessary consultation(s) with physician(s).

• Monitoring the treatment and progress of claimant’s medical condition.

• Coordination of family, agency, and community services to provide optimal recovery.

For such expenses associated with the above, the carrier personnel performing the activities must

be trained as one of the following:

• Physician

• Licensed registered nurse

• Licensed speech therapist

• Registered physical therapist

• Dentists and dental technician

• Occupational therapist

• Chiropractor

• Podiatrist

• Licensed physician assistant

• Licensed cardio-pulmonary technician

m. Plant Hospital Contributions: If the carrier furnished first aid equipment or contributes to the cost of

plant hospitals maintained by the insured or pays the salaries, in whole or in part, of medical personnel

or in any other way contributes to the cost of medical facilities maintained by the insured, report these

amounts as medical.

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If the carrier loans hospital equipment to the insured, 20% of the replacement costs new shall be

treated as actual losses paid for each year during which such equipment is on loan and also shall be

reported as medical.

n. Clinical Medical: When a carrier maintains a medical clinic, the cost of each treatment given shall be

charged against the individual risk in accordance with a fixed schedule or charges per treatment. The

schedule of charges may distinguish between types of treatment, and shall apply without exception to

all risks with cases treated by the clinic, and shall be frequently revised and adjusted if necessary so

that the total charges for a given period will be equivalent to the total cost of maintaining the clinic,

including salaries, rent, light, heat, depreciation of equipment, cost of supplies, etc.

o. Expenses Included in Medical Losses

Refer to expenses included in indemnity losses

.

p. Expenses Excluded from Medical Losses

Refer to expenses excluded from indemnity losses

.

5. Paid Amounts

Paid amounts are the amounts paid as of the valuation date. Paid amounts should be net of subrogation

recovery received and special fund reimbursements received.

6. Case Reserves

Case Reserves are amounts set aside for expected payments on a specific claim as of the valuation date.

Indemnity case reserves associated with fatal and permanent total injuries should be based on the annuity

values contained in Appendix III – Pension Tables

.

7. Reserve Discounting

Losses should be reported at nominal (undiscounted) values with the exception of death and permanent

total claims. Refer to Part I, Section VIII – Pension Tables

.

8. Incurred But Not Reported (IBNR) Reserves

Incurred But Not Reported (IBNR) Reserves are expected payments relating to insured events that have

occurred but have not been reported to the carrier as of the valuation date plus reserves to reflect

deficiencies in known case reserves.

9. Case Incurred

Case incurred is the sum of paid losses and case reserves.

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C. Claim Categories

General Information

a. Claims can be categorized as one of the following:

• Indemnity claim (i.e. lost time claim) (injury type codes

“01”, “02”, “05” and “09”) is one that has

either paid or expected indemnity losses. An indemnity claim usually has associated medical

losses.

• Medical only claim (injury type code “06”) is one that, by definition, has no indemnity losses. The

injured worker was not eligible for wage replacement, either because the worker returned directly to

work after the injury or was not out of work for more than the state-specified ‘waiting period’.

Included in this category are ALAE only claims.

b. The status of a claim can be either “Open” or “Closed”.

• Open (Outstanding) Claim (status code

“0”)

A claim for which outstanding case reserves exist as of the valuation date, regardless of whether or

not any payments have been made on the claim.

• Closed Claim (status code

“1”)

o With Payment

A claim closed with payment is one in which losses are paid in full with no existing case

reserves as of the valuation date.

o Without Payment

A claim closed with no loss payment and with no existing outstanding case reserve as of the

valuation date. This includes ALAE only claims even those with outstanding ALAE reserves.

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D. Expenses

Part D of the definitions is organized into the following components:

• Expenses Reported in Aggregate Financial Calls

• Expenses Reported in Unit Statistical Reporting Data

1. Expenses Reported in Aggregate Financial Calls

a. Other Acquisition, Field Supervision and Collection Expenses Incurred

Acquisition, field supervision and collection expenses other than commission and brokerage as

defined in the Annual Statement instructions.

b. General Expenses

Includes all general expenses, including expenses incurred for auditing, inspecting, and

administrative expenses incurred in conducting an insurance operation. General expenses

include the Boards and Bureau Expenses which are also reported separately.

c. Boards and Bureau Expenses

Boards and Bureau expenses include dues, assessments, fees, and charges of:

• Underwriting boards, rating organizations, statistical agencies, and audits bureaus

• Underwriters’ advisory and service organizations

• Accident and loss prevention organizations

• Claims organizations

• Specific payments to boards, bureaus, and associations for rate manuals, revisions, fillers,

rating plans, and experience data.

d. Incidental Income

Any revenues received from finance charges, installment fees, check bouncing fees, reinstatement

fees or similar charges, related to Massachusetts workers’ compensation policies, imposed on a

policyholder by their insurance company.

e. Unreported Expenses

Expenses associated with the collection of incidental income for workers’ compensation policies.

Do not report any amount otherwise reported in any of the other expense category.

f. Uncollectible Premium Receivables

Any premium receivable that has been written off because the determination was made that it was

uncollectible.

Note that this does not impact earned premiums or written premiums because uncollectible

premium receivables are written off against other income.

g. Loss Adjustment Expenses

For aggregate financial reporting, loss adjustment expenses can be classified into two broad

categories: Defense and Cost Containment (DCC) and Adjusting and Other (AO). Loss

adjustment expenses should be reported in accordance with the current NAIC definitions.

i. Defense and Cost Containment (DCC)

DCC includes defense, litigation, and medical cost containment expenses, whether internal or

external. DCC includes, but is not limited to, the following items:

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• Surveillance expenses;

• Fixed amounts for medical cost containment expenses;

• Litigation management expenses;

• Loss adjustment expenses for participation in voluntary and involuntary market pools if

reported by accident year;

• Fees or salaries for appraisers, private investigators, hearing representatives, reinspectors

and fraud investigators, if working in defense of a claim, and fees or salaries for

rehabilitation nurses, if such cost is not included in losses;

• Attorney fees incurred owing to a duty to defend, even when other coverage does not exist;

and

• The cost of engaging experts;

ii. Adjusting and Other (AO)

AO are claim settling expenses other than those included in DCC. AO includes, but is not

limited to, the following items:

• Fees and expenses of adjusters and settling agents;

• Loss adjustment expenses for participation in voluntary and involuntary market pools if

reported by calendar year;

• Attorney fees incurred in the determination of coverage, including litigation between the

reporting entity and the policyholder; and

• Fees and salaries for appraisers, private investigators, hearing representatives,

reinspectors and fraud investigators, if working in the capacity of an adjuster.

2. Expenses Reported in Unit Statistical Reporting Data

a. Allocated Loss Adjustment Expense (ALAE)

Expenses that are not defined as losses and are directly related to and directly allocated to the

handling of a particular claim for services that are required to be performed by statute or regulation.

ALAE encompasses the following costs:

i. Fees of attorneys or other authorized representatives where permitted for legal services,

whether by outside vendors or staff representatives.

ii. Court, Alternate Dispute Resolution, and other specific items of expense such as:

• Medical examinations of a claimant to determine the extent of the carrier’s liability, degree

of permanency, or length of disability

• Expert medical or other testimony

• Autopsy

• Witnesses and summonses

• Copies of documents such as birth and death certificates, and medical treatment records

• Arbitration fees

• Surveillance

• Appeal bond costs and appeal filing fees

iii. Medical cost containment expenses incurred with respect to a particular claim, whether by an

outside vendor or done internally by a staff representative for the purpose of controlling losses,

to ensure that only reasonable and necessary costs of services are paid. The expenses

include:

• Bill-auditing expenses for any medical or vocational services rendered, including hospital

bills (inpatient or outpatient), nursing home bills, physician bills, chiropractic bills, medical

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• equipment charges, pharmacy charges, physical therapy bills, and medical or vocational

rehabilitation vendor bills

• Hospital and other treatment utilization reviews, including precertification/preadmission, and

concurrent or retrospective reviews

• Preferred provider network/organization expenses

• Medical fee review panel expenses

iv. ALAE does not include expenses incurred to recover subrogation.

3. Expenses Not Reported

a. Unallocated Loss Adjustment Expense (ULAE)

ULAE includes, but is not limited to:

i. Carrier employees’ salaries, overhead, and traveling expenses that are considered loss

adjustment expenses and are not incurred while doing activities listed as allocated expenses.

ii. Fees paid to independent claims professionals or attorneys hired to perform the function of

claim investigation normally performed by claim adjusters.

iii. Fees paid for developing and investigating a claim so that a determination can be made of the

cause or extent of responsibility for the injury or disease, including evaluation and settlement of

covered claims.

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E. Experience Types

1. Voluntary

a. Guaranteed Cost and Retrospectively Rated

• Guaranteed Cost

A standard workers' compensation insurance policy that is not subject to premium adjustment

due to losses that occur during the policy term. In a guaranteed cost policy, the only variable

affecting premium that is expected to change between policy inception and audit is exposure.

This is in contrast to retrospective rating, where premium adjustments are made based on

losses incurred during the policy term.

• Retrospective Rating

A workers' compensation insurance policy that periodically makes adjustments to the premium,

after policy expiration, based on the actual losses generated during the policy term. The

premium adjustments are constrained by a maximum premium and a minimum premium. See

the Retrospective Rating Plan Manual

.

b. Large Deductible

Massachusetts large deductible rating plans are optional and allow insurance companies to offer

large insureds per claim deductibles of $75,000 or more (subject to an aggregate limitation of loss

amounts below the deductible). Insureds reimburse the insurer for losses below a specified

threshold, the deductible, and in return, receive a premium credit.

c. National Defense Project Plan

A rating plan that applies to risks working on national defense projects when the operations are

performed under a contract that provides that the contractor (insured) is reimbursed for the cost of

this insurance by the US government.

d. Excess Workers’ Compensation

Previous Annual Statement reporting instructions allowed Excess Workers’ Compensation, excess

coverage purchased by a self-insured on a per-occurrence or per-claim basis above a self-insured

retention, to be reported on the workers’ compensation line (Line 16.0) of the Exhibit of Premium

and Losses (Statutory Page 14). This is no longer the case. Effective calendar year 2009, Excess

Workers’ Compensation should be reported on the excess workers’ compensation line (Line 17.3)

of Statutory Page 14.

2. Residual Market

The Massachusetts Workers' Compensation Assigned Risk Pool was created by statute to provide a

means for Massachusetts employers, who are unable to obtain workers’ compensation coverage from a

licensed insurer in the voluntary market, to satisfy their obligations under M.G.L. Chapter 152. The

Massachusetts Workers' Compensation Assigned Risk Pool must provide coverage to any employer

who is entitled to workers’ compensation insurance.

a. Normal Assigned Risk

A servicing carrier is a designated member company of the Massachusetts Workers' Compensation

Assigned Risk Pool that issues policies and provides services to assigned employers in return for a

servicing carrier fee paid by the Massachusetts Workers' Compensation Assigned Risk Pool.

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The loss and premium results generated by the servicing carrier are pooled and shared with all

members of the Massachusetts Workers’ Compensation Assigned Risk Pool via an assessment of

Pool participants.

b. Voluntary Direct Assigned Program

The Pool Plan of Operation of the Massachusetts Workers' Compensation Assigned Risk Pool,

provides that any insurer, if authorized by DOI, may satisfy its assessment obligations as a member

of the Massachusetts Workers' Compensation Assigned Risk Pool by accepting voluntary direct

assignments of risks. The voluntary direct assignment carrier issues the policies and provides

service to assigned employers.

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F. Class Categories

1. Federal “F” Classification

The U.S. Longshore and Harbor Workers Compensation Act (USL&HW Act) is a federal law which

provides for payment of compensation and other benefits to employees such as longshoremen, harbor

workers, ship repairmen, shipbuilders, shipbreakers and other employees while working on loading,

unloading, repairing or building a vessel. “F” Classifications include premium for operations subject to

the USL&HW Act.

Refer to the Massachusetts Workers Compensation and Employers Liability Insurance Manual

.

2. Maritime

The Merchant Marine Act of 1920, also known as the Jones Act, grants crew members a cause of

action against their employer for negligence that results in injury or death.

Refer to the Massachusetts Workers Compensation and Employers Liability Insurance Manual

.

PART IV

EXAMINATIONS

AND

RECONCILIATIONS

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PART IV – EXAMINATIONS AND RECONCILIATIONS

A. Unit Statistical Reports and Aggregate Financial Data Reconciliations

The WCRIBMA will routinely work with its member carriers to attempt to reconcile the unit statistical

data to the aggregate financial data that is submitted to the WCRIBMA for each policy year at the

latest evaluation. The WCRIBMA will also attempt to reconcile the aggregate financial data to the

annual statements each carrier group submits to the DOI. During this process, the carrier group may

be subject to fines under the provisions of the Statistical Plan’s Data Quality Compliance Programs.

The data submitted by each carrier group to the WCRIBMA will be tested for compliance with the

tolerances set forth in Part IV – Examinations and Reconciliations. In accordance with the timetable

prescribed in Part II, Section II – Aggregate Financial Reporting Timetable

, each carrier group will

have an opportunity to work with the WCRIBMA to provide corrections or explanations for any data

falling outside the established tolerances. At the end of this prescribed time period, the WCRIBMA will

report to the DOI all carrier group data falling outside allowable tolerances (tolerance variances).

If a carrier group provides what the WCRIBMA deems to be an acceptable explanation for its

tolerance variances, the WCRIBMA will report the tolerance variances to the DOI with an explanation

as to why it believes the carrier group’s data reporting activities do not need to be examined on-site

by an independent auditing firm. Any carrier group’s uncorrected or unexplained tolerance variances

that are reported to the DOI, and any carrier group whose explanations are deemed insufficient by the

DOI will, at the carrier group’s expense, have an independent auditing firm perform an Targeted

Agreed-Upon Procedures Engagement. The Targeted Agreed Upon Procedures (Targeted AUP) with

regard to the data reporting activities relating to the specific data in question for any carrier group with

such variances will be determined by the WCRIBMA in consultation with the DOI.

5

In accordance with the timetable prescribed in

Part II, Section II – Aggregate Financial Reporting

Timetable, the independent auditing firm will conduct the Targeted AUP and submit to the DOI and

the WCRIBMA a findings report which describes the procedures performed by the firm and its

findings. For each carrier group, any applicable work papers, including any applicable tables showing

the reported and reconciled data together with a CD containing the data examined will be submitted

by the auditing firm to the WCRIBMA and the DOI. The independent auditing firm’s findings report

will also be provided to the carrier group by WCRIBMA within 10 days after receiving it from the

independent auditing firm. Upon receipt of the findings report, the carrier group will be given not more

than thirty (30) days to make a written submission to the DOI and the WCRIBMA responding to the

findings report prior to any final determination by the WCRIBMA or the DOI regarding the

appropriateness of the carrier group’s data submissions.

1. Unit Statistical Reports and Aggregate Financial Reconciliation

a. Rationale

Both unit statistical reports (USR) and aggregate financial data (AF) as detailed in Part I and

Part II of the Statistical Plan respectively, call for the reporting of premium and loss

information. Despite timing and definitional differences between the submission and valuation

5

An Agreed-Upon Procedures Engagement is one in which a practitioner is engaged to issue a report of

findings based on specific procedures performed on the designated subject matter. The application of

agreed-upon procedures engagements is discussed in AICPA Statements on Standards for Agreed-Upon

Procedures Engagements (“AT 201”).

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of USR and aggregate financial data, meaningful comparisons can be made between these

two sources of data as a test for consistency.

b. Comparisons

Policy year premium and policy year loss data submitted on USRs will be compared to

comparable policy year aggregate financial data by carrier group. Aggregate financial data

will be the sum of the Policy Year Call, Policy Year Large Deductible Call, Policy Year F-

Class Call and Policy Year Maritime Call. Five policy years will be compared as follows:

Policy Year

Unit

Statistical

Report Level

USR Age

(in months)

Aggregate

Financial

Valuation Date

Aggregate

Financial Age

(in months)

XXXX – 4 Fifth 66 12/31/XXXX+1 72

XXXX – 3 Fourth 54 12/31/XXXX+1 60

XXXX – 2 Third 42 12/31/XXXX+1 48

XXXX – 1 Second 30 12/31/XXXX+1 36

XXXX First 18 12/31/XXXX+1 24

c. Data Tested

The specific data elements to be reviewed are:

• Policy Year Accumulated Earned Premium - Standard at Bureau DSR Level

• Indemnity Paid

• Medical Paid

• Indemnity Paid + Case

• Medical Paid + Case

Note that USR standard premium is defined differently from Aggregate Financial

standard premium. Consequently, adjustments will be made to the USR standard premium

to facilitate the reconciliation to the aggregate financial data. Specifically, the USR standard

premium used in the comparison will include the expense constant reported under statistical

class code 0900 and it will exclude schedule rating credits, deviations, and deductible credits

reported under statistical class codes 0887, 9037, and 9664.

d. Tolerances

The reconciliation will calculate ‘differences’ and ‘percentage differences’ which will be

compared against the applicable tolerances.

The difference and percentage difference for a given data element will be calculated as:

Difference = USR Value – Aggregate Financial Value

Percentage Difference = [(USR Value – Aggregate Financial Value) / USR Value] x 100

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To be considered within tolerance, the reviewed data elements must meet either Condition A

or Condition B.

Condition A – Difference must be within +/- the acceptable amount specified below.

Condition B – Difference must be within +/- the acceptable amount specified below AND the

percentage difference must be within +/- the acceptable amount specified below.

Condition A Condition B

Data

Element

AF

Age in

Months

USR

Age in

Months

Difference

Percentage

Difference

Standard

Premium

72

66

50,000

10%

1,000,000

60

54

50,000

10%

1,000,000

48

42

50,000

10%

1,000,000

36

30

50,000

10%

1,000,000

24

18

100,000

20%

2,000,000

Losses

72

66

100,000

10%

1,000,000

60

54

100,000

10%

1,000,000

48

42

100,000

10%

1,000,000

36

30

200,000

15%

1,500,000

24

18

300,000

20%

2,000,000

e. USR and Aggregate Financial Reconciliation Report Format

USR and Aggregate Financial Reconciliation

NAIC Carrier Group Code: 99999

NAIC Carrier Group Name: ABC Insurance Group

Data Element: Standard Premium (in $000)

Aggregate

Financial

USR

Policy

Year

(1)

Age in

Months

(2)

Amount

(3)

Age In

Months

(4)

Amount

(5)

Percentage

Difference

[(5)-(3)]/(5)

(6)

Difference

(5)-(3)

(7)

Within

Tolerance

(8)

XXXX - 4

72

18,262

66

20,557

11.2%

2,295

N

XXXX - 3

60

22,415

54

22,804

1.7%

389

Y

XXXX - 2

48

20,572

42

21,501

4.3%

929

Y

XXXX - 1

36

21,927

30

22,556

2.8%

629

Y

XXXX

24

20,034

18

22,224

9.9%

2,190

N

The WCRIBMA will report to the Massachusetts Division of Insurance all carrier groups with data

falling outside allowable tolerances.

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2. USR Manual Rate and Premium Reconciliation

a. Rationale

Manual rates reported in accordance with the instructions herein should not reflect any

deviations or discounts from the WCRIBMA’s filed and approved rates. The manual rates

reported on unit statistical data should equal the WCRIBMA’s filed and approved rates.

b. Comparisons

The latest five composite policy years will be reconciled by carrier group.

For this report, a composite policy year is the aggregation of all policies with effective dates

between July 1 of one year and June 30 of the next year. For example, composite policy

year 2003 includes all policies with effective dates from July 1, 2003 to June 30, 2004.

c. Data Tested

Rates for manual class codes submitted on unit statistical reports are compared to the

WCRIBMA’s filed and approved rates based on the USR reported rate effective, modification

effective and policy effective dates.

Premiums for manual classes submitted on unit statistical reports are compared to a

“calculated manual premium” which is based on the exposure reported on the USR and the

WCRIBMA’s filed and approved rate based on the USR reported rate effective.

Composite policy years where a carrier group has less than $100,000 in calculated manual

premium will not be tested.

d. Tolerances

For this report, records where the reported manual rate is not the same as the WCRIBMA’s

filed and approved rate are referred to as unmatched records. Similarly, records where the

reported manual rate is the same as the WCRIBMA’s filed and approved rate are referred to

as matched records.

Manual Rates - If 5% or more of USR non statistical records for a given composite policy year

are unmatched, the carrier group is outside of tolerance.

Manual Premiums – If the percentage difference between the reported manual premiums and

the calculated manual premiums is not within +/- 5%, the carrier group is outside of tolerance.

The percentage difference for manual premiums will be calculated as:

Percentage Difference = [(Reported Value - Calculated Value) / Calculated Value] x 100

e. USR Manual Rate and Premium Reconciliation Report Format

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The WCRIBMA will report to the Division of Insurance all carrier groups with data falling outside

allowable tolerances.

3. Aggregate Financial Standard at Designated Statistical Rate Level Premium and Aggregate

Financial Net Premium Reconciliation

a. Rationale

Comparisons made between Standard Earned Premium at DSR to the Net Premium, both

submitted on the Aggregate Financial Data calls, help to monitor consistency in reporting.

b. Comparisons

Call # 4 – Reconciliation Report, page 3 will be the basis for the report.

c. Data Tested

The specific data elements to be reviewed are:

 Policy Year Accumulated Earned Premium - Standard at Bureau DSR Level

 Policy Year Accumulated Earned Premium - Net Premium

d. Tolerances

Only carrier groups with an imbalance falling within the range of +/- $100,000 are considered

to be within tolerance. Note that the calculated imbalance is equal to line 24 from page 3 of

the Call # 4 -Reconciliation Report.

USR Manual Rates and Manual Premium Reconciliation

Summary by Carrier Group

NAIC Carrier Group Code: 99999

NAIC Carrier Group Name: ABC Insurance Group

Manual Rates

Manual Premiums

Composite

Policy

Year

Total

Number of

USR

Exposure

Records

Number of

Exposure

Records

Matching

Number of

Exposure

Records

Not

Matching

Percent

of

Exposure

Records

Within

tolerance

Manual

Premium

Reported

Calculated

Manual

Premium

(Using

Approved

Rates)

Manual

Premium

Percent

Difference

Within

Tolerance

Or

Indicator

(2) - (3)

(4) / (2)

[(7)–(6)]/(7)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

XXXX - 4 25,000 24,500 500 2.00% 3,000,000 3,129,000 4.1% Y

XXXX - 3 22,000 21,800 200 0.91% 2,800,000 2,702,000 -3.6% Y

XXXX - 2 26,000 25,500 500 1.92% 3,200,000 3,643,380 12.2% N

XXXX - 1 23,000 18,500 4,500 19.57% 3,200,000 3,139,520 -1.9% N

XXXX 18,000 17,900 100 0.56% 2,400,000 2,400,000 0.0% Y

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Part IV – Examinations and Reconciliations Page 6

In addition to carrier groups falling outside of the tolerances, any carrier group utilizing a

“write-in” adjustment as part of the reconciliation will be included on the report made to the

DOI.

e. Aggregate Financial Standard at Designated Statistical Rate Level Premium and Aggregate

Financial Net Premium Reconciliation Report Format

Aggregate Financial Standard Earned at Designated Statistical Rate Level

Premium and Aggregate Net Premium Reconciliation

Calendar Year 2010

Amount in Thousands

NAIC

Group

Number

Aggregate

Financial

Std EP @

DSR

Aggregate

Financial Net

Earned

Premium

Listed

Write In

Imbalance

(2)+(4)+(5)-(3)

(1) (2) (3) (4) (5) (6)

88888 225,000 205,000 20,000 189,000 172,000

4. Aggregate Financial and Annual Statement Reconciliation

a. Rationale

Comparisons made between Aggregate Financial Data and data submitted on Annual

Statements help to monitor consistency in reporting. Calendar year premium and loss

information can be calculated using the policy year data submitted on the Aggregate

Financial Data calls which can then be compared to Statutory Page 14 of the Annual

Statement.

b. Comparisons

Call # 4 – Reconciliation Report, page 3 will be the basis for the report.

c. Data Tested

The specific data elements to be reviewed are:

• Direct Earned Premium

• Incurred Losses

d. Tolerances

Only carrier groups with an imbalance falling within the range of +/- $100,000 are considered

to be within tolerance. Note that the calculated imbalance for direct earned premium is equal

to line 22 from page 1 of the Reconciliation Report call and that the calculated imbalance for

incurred losses is equal to line 19 from page 2 of the Call # 4 - Reconciliation Report.

In addition to carrier groups falling outside of the tolerances, any carrier group utilizing a

“write-in” adjustment as part of the reconciliation will be included on the report made to the

DOI.

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Part IV – Examinations and Reconciliations Page 7

e. Aggregate Financial and Annual Statement Reconciliation Report Format

Aggregate Financial and Annual Statement Reconciliation

Calendar Year 2010

Amounts in Thousands

Data Element: Direct Earned Premium

NAIC

Group

Number

(1)

Aggregate

Financial

Earned

Premium

(2)

Annual

Statement

Earned

Premium

(3)

Listed

(4)

Write In

(5)

Imbalance

(2)+(4)+(5)-(3)

(6)

88888 144,000 142,200 1,800 1,500 (200)

B. Routine Reviews by the WCRIBMA (Targeted AUP)

1. The WCRIBMA will review the data submitted by each of the carrier groups. If the WCRIBMA

identifies any anomalies or questionable patterns in the data submitted, WCRIBMA staff will work

with the carrier group to obtain corrections or valid explanations of the anomalous or questionable

data. During this process, the carrier group may be subject to fines under the provisions of the

Statistical Plan’s Data Quality Compliance Programs. A carrier group’s questionable data must

be resolved to the WCRIBMA’s satisfaction within the timetable prescribed in

Part II, Section II –

Aggregate Financial Reporting Timetable. Any questionable patterns that might reasonably be

expected to affect the suitability of the data for use in ratemaking will be reported to the DOI in

accordance with the timetable prescribed in

Part II, Section II – Aggregate Financial Reporting

Timetable.

Whenever issues relating to a carrier group’s questionable data, that are deemed to be of

material significance to the DOI or the WCRIBMA, are not resolved to the WCRIBMA’s or DOI’s

satisfaction, the WCRIBMA shall engage an independent auditing firm, at the carrier group’s

expense, to perform and on–site Targeted AUP, responsive to the unresolved issues. Such

Targeted AUP shall be determined by the WCRIBMA in consultation with the DOI. Such Targeted

AUP Engagements shall not be required to occur under the timetable prescribed in

Part II,

Section II – Aggregate Financial Reporting Timetable. The independent auditing firm will conduct

the Targeted AUP and submit to the DOI and the WCRIBMA a findings report which describes

the procedures performed by the firm and its findings. For each carrier group, any applicable work

papers, including any applicable tables showing the reported and reconciled data together with a

CD containing the data examined will be submitted by the auditing firm to the DOI and the

WCRIBMA. The independent auditing firm’s findings report will also be provided to the carrier

group by WCRIBMA within 10 days after receiving it from the independent auditing firm.

Upon receipt of the findings report, the carrier group will be given not more than thirty (30) days to

make a written submission to the DOI and the WCRIBMA responding to the findings report. The

30 day response period provided to the carrier group shall not prohibit the WCRIBMA from

making any determination regarding the appropriateness of the carrier group’s data submissions.

The DOI will, however, withhold any findings regarding the appropriateness of the carrier group’s

data submissions for 30 days after the conclusion of the Targeted AUP Engagement.

2. Targeted Agreed Upon Procedures By Independent Auditing Firms

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The WCRIBMA will seek to ensure that the above referenced Targeted AUP will be conducted by

an independent auditing firm that does not have a current audit relationship with the carrier

subject to the on-site exam. The WCRIBMA will provide the DOI with the names of the

independent auditing firms it intends to engage to conduct the Targeted AUPs. The carrier group

will be obligated to provide the independent auditing firm with an adequate work space during

normal business hours and to reimburse the firm for associated travel expenses incurred during

the course of any on-site visit.

Applicable Targeted AUP costs are initially subject to a calendar year presumptive billing limit

equal to the greater of $50,000 or .5% of the carrier group’s direct workers’ compensation earned

premium for the state of Massachusetts as reported on Statutory Page 14 of the Annual

Statement for the prior calendar year. Therefore, the WCRIBMA shall engage only such auditing

firms as agree to a presumptive billing limit for the costs associated with performance of their

contract. If a carrier group did not file an Annual Statement for the prior calendar year, the

Annual Statement most recently filed prior to the current year is to be used in the calculation of

the above-described presumptive billing limit. If no annual statements have been filed prior to the

current year, a Targeted AUP presumptive billing limit of $50,000 will apply. A presumptive billing

limit may be increased by the WCRIBMA only following a detailed written submission from the

independent auditing firm which establishes to the satisfaction of the WCRIBMA that the firm

cannot complete the Targeted AUP and submit a findings report within such limit.

The independent auditing firm’s periodic invoices for the on-site Targeted AUP shall be submitted

to the carrier group, through the WCRIBMA, and will be payable upon receipt by the carrier

group. Any carrier group that fails to timely pay any invoice for an on-site Targeted AUP pursuant

to the Statistical Plan shall be reported to the DOI for appropriate action.

C. Routine Engagements by Independent Auditing Firms (Triennial AUP)

Any carrier group with at least a one percent (1%) market share in any of the three calendar years

immediately preceding the latest calendar year for which Annual Statements have been filed, will be

required to engage its independent auditing firm (the auditing firm used by the carrier group to audit

their most recent year-end financial statements) or another independent auditing firm of its choice to

perform an on-site Triennial AUP Engagement. Carrier group market shares will be based on

calendar year earned premiums for the Massachusetts workers’ compensation line as reported on

Statutory Page 14. The WCRIBMA will notify those carrier groups that will be subject to a Triennial

AUP for any given year. The carrier groups selected for a Triennial AUP Engagement in any given

year shall be determined by the WCRIBMA in consultation with the DOI. The routine Triennial AUP is

to be performed at the carrier group’s expense. Carrier groups will not be required to perform a

routine on-site Triennial AUP Engagement more frequently than once every three years.

The Triennial AUP with regard to the underlying internal control environment (premiums and claims

systems) governing Aggregate Financial data will be proposed by the WCRIBMA for approval by the

DOI and will result in a findings report that will be submitted to the DOI, the WCRIBMA and the carrier

group in accordance with the timetable prescribed in

Part II, Section II – Aggregate Financial

Reporting Timetable.

Upon receipt of the findings report, the carrier group will be given not more than thirty (30) days to

make a written submission to the DOI and the WCRIBMA responding to the findings report. The 30

day response period provided to the carrier group shall not prohibit the WCRIBMA from making any

determination regarding the appropriateness of the carrier group’s data submissions. The DOI will,

however, withhold any findings regarding the appropriateness of the carrier group’s data submissions

for 30 days after the conclusion of the Triennial AUP Engagement.

PART V

DATA QUALITY COMPLIANCE

PROGRAMS

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

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Part V – Data Quality Compliance Programs Page 1

PART V - DATA QUALITY COMPLIANCE PROGRAMS

A. Overview

The Data Quality Compliance Program was developed in response to an order of the Commissioner

of Insurance. The timely collection of unit statistical report (USR) data and aggregate financial (AF)

call data is critical for providing the source data that is used in the development of workers’

compensation rates. To ensure the inclusion of your data in the rate filing, it is necessary that the

WCRIBMA receives accurate data on or before the applicable due dates.

The Data Quality Compliance Program does not apply to workers’ compensation self-insurance

groups.

There are four data quality programs. These are:

• Unit Statistical Data Quality Incentive Program (USDQIP)

• Aggregate Financial Call Acknowledgment Process

• Aggregate Financial Data Quality Incentive Program (AFDQIP)

• Examinations and Reconciliations

B. Unit Statistical Data Quality Incentive Program (USDQIP)

USDQIP provides carriers with an incentive to submit unit statistical data in a timely manner. The

timeliness of unit statistical reporting is measured in relation to the corresponding policy’s effective

date. Penalty determinations will be based on the number of months past the policy effective date of

the unit.

Carriers will be subject to timeliness fines for the following:

1. Missing Policy Information Fines

USR data, for which there is no corresponding, previously submitted policy in the WCRIBMA’s

data base will be rejected by the WCRIBMA.

Unit statistical reports that are rejected due to missing policy information are subject to fine if the

policy information is not successfully submitted and the unit statistical report is not accepted, or

not otherwise resolved, before the 21

st

month from the policy effective date.

The fines will be $100 per month, for 6 consecutive months. The fines then increase to $200 per

month thereafter.

Timeliness Example: A unit statistical report corresponding to a policy effective any day during

January, 2007, is rejected due to missing policy information. If the policy is not successfully

submitted and the unit statistical report is not accepted or not otherwise resolved by the end of

the 20

th

month following the policy effective date, the carrier will incur the first fine in the 21

st

month, October, 2008, and will be fined each subsequent month until resolution.

2. Delinquent Unit Statistical Reports Fines

A “Delinquent and Fined” USR is a unit statistical report for a policy within the WCRIBMA’s data

base, which has not been successfully submitted to the WCRIBMA and is more than 20 months

(and in the case of subsequent reports that are due 30 months, 42 months, etc.) past the end of

the month in which the corresponding policy became effective. If a policy record is received more

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Part V – Data Quality Compliance Programs Page 2

than 20 months after the policy effective date, the policy will be listed under the Delinquent and

Fined status.

Delinquent USRs will be fined in the 21st month and each month thereafter, until the unit

statistical report is successfully submitted or the Delinquent and Fined status is otherwise

resolved.

The fines will be $100 per month, for 6 consecutive months. The fines then increase to $200 per

month thereafter.

Timeliness Example: A unit statistical report corresponding to a policy effective any day during

January, 2007, but that has not been successfully submitted to the WCRIBMA, is posted with due

status in July, 2008. If the USR is not successfully submitted or other resolution reached, or

corrective action is not received by the end of the 20

th

month, the carrier will incur the first fine in

the 21

st

month, October, 2008, and will be fined each subsequent month until resolution.

3. Rejected Correction Reports Fines

Correction reports which remain in rejected status for three (3) months, following the last day of

the month in which the unit was rejected, will be fined at a rate of $100 per month, for 6

consecutive months. The fines then increase to $200 per month, thereafter.

Timeliness Example: A USR correction report is received at the WCRIBMA on any day in

January, 2010 and is rejected by the WCRIBMA. If the rejected correction is not resolved by the

reporting carrier, within the 3 months following the month in which the unit was rejected,

(February, March, April) the carrier will incur the first fine on May 1, 2010 and will be fined each

subsequent month until resolution.

C. Aggregate Financial Call Acknowledgment Process

The Aggregate Financial Call Acknowledgment Process was established to emphasize the

importance of timely and accurate data. The Aggregate Financial Call Acknowledgment Process

requires the completion of the Aggregate Financial Call Acknowledgment Form by a company officer

or a company actuary who is a member of the Casualty Actuarial Society and/or a member in good

standing of the American Academy of Actuaries. This serves to confirm that the aggregate financial

call data that relates to ratemaking has been prepared to the best of your organization’s professional

abilities and are accurately represented.

1. Timeliness Fines

Forms that are submitted after the due date will accrue fines at a rate of $250 per business day

for the first 30 business days overdue. Fines will accrue at the rate of $1,000 per business day

for the next 30 business days after which fines will accrue at the rate of $2,500 per business day

until such time as the form has been submitted.

2. Inappropriate Signatory Fines

Forms that are submitted without the signature of a company officer or a company actuary who is

a member of the Casualty Actuarial Society and/or a member in good standing of the American

Academy of Actuaries will incur a fine of $1,000.

If a carrier does not submit a corrected form to the WCRIBMA within 5 business days of the

WCRIBMA’s notification to the carrier, additional fines will begin to accrue at the rate of $250 per

MASSACHUSETTS WORKERS’ COMPENSATION

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Part V – Data Quality Compliance Programs Page 3

business day for the first 30 business days. Fines will accrue at the rate of $1,000 per business

day for the next 30 business days after which fines will accrue at the rate of $2,500 per business

day until such time that the form is submitted with the appropriate signatory in accordance with

the Statistical Plan.

D. Aggregate Financial Data Quality Incentive Program (AFDQIP)

AFDQIP provides carriers with an incentive to submit aggregate financial data in a timely and

accurate manner. Late and/or inaccurate reporting of data will subject carriers to timeliness and/or

data quality fines. The fines under the AFDQIP will be assessed on either a carrier group basis or an

individual carrier basis, consistent with the manner in which the data is reported.

1. Timeliness Fines

Carriers will be notified via email five business days before the call deadline for pending call

submissions. Notification will be sent to the person designated as the primary contact for all calls

and the person designated as the contact for a given call (if different than the primary contact).

A request to submit overdue calls will be emailed to delinquent data reporters five business days

after the call due date. This request will be sent to the person designated as the primary contact

for all calls and the person designated as the contact for a given call (if different than the primary

contact). Daily fines will begin to accrue at a rate of $250 per business day per call for the first 30

business days beyond the date of the second email. Beyond 30 business days, fines will accrue

at the rate of $1,000 per business day per call for the next 30 business days after which fines will

accrue at the rate of $2,500 per business day per call.

Timeliness fines will continue to accrue until a complete call is submitted.

2. Data Quality Fines

All submitted data is subjected to a number of edits designed to help the WCRIBMA identify data

anomalies. Some data anomalies may be the result of errors in data submission while other data

anomalies reflect accurately reported data resulting from atypical circumstances. The edits used

by the WCRIBMA are categorized into two groups, Basic Edits and Actuarial Edits.

• Basic Edits

Basic edits are intended to identify incorrect data. For example, reported policy year

standard premiums should always be non-negative values. A carrier submitting a negative

value for policy year standard premium has made a mistake. In addition to sign conventions,

Basic Edits also check to see that premiums have been reported for any policy year for which

losses have been reported.

Basic edit failures result in per occurrence fines. Additionally, Basic Edit failures will result in

timeliness fines if not corrected within 10 business days. There are no acceptable

explanations for Basic Edits failures. All Basic Edit failures must be corrected.

Per Occurrence Fines - Each finable Basic Edit failure results in a fine of $250. Note that a

single error condition can generate multiple errors within and across calls, with the generated

errors resulting in fines of $250 each. For example, assume that a carrier submits a policy

year call where the standard premium at designated statistical rate is reported as a negative

value for six separate policy years. This would result in a fine of $1,500 (6 x $250).

MASSACHUSETTS WORKERS’ COMPENSATION

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Part V – Data Quality Compliance Programs Page 4

Timeliness Fines – Carriers will have 10 business days to correct Basic Edit failures. Beyond

the 10 business day grace period, fines will accrue at the rate of $250 per business day per

call for the first 30 business days. Fines will accrue at the rate of $1,000 per business day

per call for the next 30 business days after which fines will accrue at the rate of $2,500 per

business day per call.

Basic Edit Testing - Before submitting data to the WCRIBMA, member carriers may utilize

WCRIBMA provided tools to test data against Basic Edits. These tools may be used

repeatedly before making any initial call submission or any correction submission.

For example, assume that a carrier is working on their reporting of the Policy Year call. The

Policy Year call data may be uploaded to the WCRIBMA’s website. At this point the data is

termed “saved” and not “submitted.” The “saved” data may then be tested by running the

Basic Edits against the data. Based on the results of the Basic Edit testing, the carrier may

make any necessary corrections.

• Assuming no changes are warranted, the carrier can proceed to “submit” the data.

• Assuming, for example, the Basic Edits flag a number of records because negative policy

year premium amounts were reported, the “saved” data may be corrected and

subsequently retested. This process may be repeated as often as necessary. Once the

carrier has resolved all data issues flagged by the Basic Edits, the carrier can proceed to

“submit” the data. The WCRIBMA will review the Basic Edits report for the submitted call.

Note that only “submitted” data that fails Basic Edits will be subject to fines. Also, once a call

is submitted it is subject to fines. Data quality fines apply if a correction is required for a

submitted call, even if corrected prior to the call due date.

• Actuarial Edits

Actuarial Edits are intended to ensure:

• consistency of Aggregate Financial data within a call

• consistency of Aggregate Financial data between Aggregate Financial calls

• consistency of Aggregate Financial data with Unit Statistical Reports

• reasonableness of changes between valuations

Data flagged as a result of the Actuarial Edit process is atypical but not necessarily incorrect

data. Consequently, to resolve issues with data flagged by Actuarial Edits carriers must

supply an acceptable explanation for the data anomaly or the data must be corrected.

Acceptable explanations must describe, to the satisfaction of the WCRIBMA’s actuarial staff,

the circumstances that caused the anomaly.

The following would be deemed unacceptable explanations by the WCRIBMA:

• explanations that simply identify the source of the error

• explanations that simply state that the reported data is correct as filed without sufficient

documentation to allow for the WCRIBMA’s evaluation

For each Actuarial Edit that flags a data anomaly, carriers must provide the WCRIBMA either

an acceptable explanation or corrected data within 10 business days of being notified of the

data anomaly. Please note that each response must be reviewed and accepted by the

MASSACHUSETTS WORKERS’ COMPENSATION

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Part V – Data Quality Compliance Programs Page 5

WCRIBMA’s actuarial staff within the allotted 10 business day time frame. Therefore, data

reporters should reply in a timely manner to allow sufficient time for the WCRIBMA to request

further clarifying information. Business days will not be counted during the time that the

WCRIBMA’s actuarial staff is reviewing an explanation or a correction.

For example, assume that a carrier submits a call which results in an actuarial edit. The

carrier will be notified via email of any flagged actuarial edits that have not been resolved.

The carrier reviews the data and sends an explanation or a correction after 3 business days.

WCRIBMA’s actuarial staff will review carrier’s response. The time that the actuarial staff

reviews the response is not counted in the time frame of 10 business days. If the WCRIBMA

requests further clarifying information the carrier has 7 business days remaining to provide an

acceptable explanation or corrected data.

Acceptable responses not received within 10 business days are deemed late and will result in

fines. For each applicable Actuarial Edit, fines will accrue at a rate of $250 per business day

for the first 30 business days overdue. Beyond 30 business days, fines will accrue at the rate

of $1,000 per business day for the next 30 business days after which fines will accrue at the

rate of $2,500 per business day until an acceptable explanation has been submitted.

In addition, revisions to data may generate further errors and result in additional fines. Data

Reporters should take this into consideration because revisions that trigger other edit failures

do not warrant an additional 10 business days to resolve. Fines will be levied for each

business day until an acceptable explanation or correction is submitted.

3. Caps Applicable to Fines Relating to Timeliness and Data Quality

Fines associated with Timeliness and Data Quality Edits are subject to a cap which is a function

of calendar year earned premium. The calendar year earned premium used to calculate the caps

is derived by taking the difference of policy year standard earned premiums at the designated

statistical reporting level for successive valuation dates. The applicable policy year premiums are

the totals for all policy years taken from the following calls:

• CALL # 2 : POLICY YEAR CALL

• CALL #2C: POLICY YEAR LARGE DEDUCTIBLE CALL

• CALL #2D: POLICY YEAR “F” CLASSIFICATION CALL

• CALL #2E: POLICY YEAR MARITIME CLASSIFICATION CALL

For calls due in a year XXXX the calendar year earned premium applied in capping will be for

year XXXX – 2. For example, calls due to be submitted in 2007 will be subject to a cap based on

calendar year 2005 earned premiums at the designated statistical reporting level.

The maximum total fine for all calls due is a given year is limited to the greater of $15,000 or 0.5%

of the applicable earned premium at the designated statistical reporting level.

E. Examinations and Reconciliations

1. Targeted AUP

The WCRIBMA will annually perform certain reconciliations as mandated by the Massachusetts

Commissioner of Insurance. If the mandated reconciliations identify unexplained data anomalies

which are not resolved in accordance with the established timeline, the insurance group to which

the carrier belongs is subject to an on-site targeted examination by an auditing firm charged with

preparing a Findings Report relative to the data in question. See

Part IV – Examinations and

Reconciliations for complete details.

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013

Part V – Data Quality Compliance Programs Page 6

2. Triennial AUP

Additionally, insurance groups with market shares exceeding a given threshold are subject to a

triennial AUP requirement. See Part IV – Examinations and Reconciliations

for complete details.

• Findings Reports

Findings reports related to a triennial examination that is submitted after the due date will

accrue fines at a rate of $250 per business day for the first 30 business days. Fines will

accrue at the rate of $1,000 per business day for the next 30 business days after which fines

will accrue at the rate of $2,500 per business day until such time as the Findings Report has

been submitted.

F. Disciplinary Fine

In addition to the fines described above, the WCRIBMA may impose a Disciplinary Fine.

1. Reasons for Disciplinary Fine:

a. If, in any filing the WCRIBMA makes with the Division of Insurance, it becomes necessary for

the WCRIBMA to adjust, correct, or make allowances for inaccuracies in the data supplied by

a carrier or carrier group.

b. If the WCRIBMA deems the data unsuitable for use in any WCRIBMA filing.

c. A carrier or carrier group is not responsive to the WCRIBMA’s request to submit overdue

calls.

d. A carrier or carrier group is not responsive or does not satisfactorily respond to the

WCRIBMA’s attempts to resolve data anomalies.

e. If the WCRIBMA, in its sole discretion, determines that a carrier group is uncooperative with

the WCRIBMA and/or the auditing firm designated to prepare the findings report related to a

Targeted AUP in accordance with Part IV – Examinations and Reconciliations

.

f. A carrier group does not comply with the triennial examination requirement as outlined in

Part

IV – Examinations and Reconciliations.

g. A carrier group has data which is missing, rejected, or filtered from the annual summary

review that will be excluded from the data reconciliation process.

h. In addition to any authority the Commissioner of Insurance already has, the Commissioner

may, at his or her discretion, require the WCRIBMA to impose a fine upon a reporting carrier

or carrier group in the amount set forth above if, after written notice and a hearing, the

Commissioner finds that any reporting entity’s aggregate financial data is unreliable,

incomplete, untimely or otherwise defective and that such defect has materially impacted a

filing submitted to the Commissioner.

2. Calculation of Disciplinary Fine

a. Disciplinary Fine for Reasons a through f:

The Disciplinary Fine is designed so that it is a function of calendar year earned premium.

The calendar year earned premium used to calculate the Disciplinary Fine is derived by

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013

Part V – Data Quality Compliance Programs Page 7

taking the difference of policy year standard earned premiums at the designated statistical

reporting level for successive valuation dates. For calls due in a year XXXX the calendar

year earned premium applied in capping will be for year XXXX – 2. For example, calls due to

be submitted in 2007 will be subject to a cap based on calendar year 2005 earned premiums

at the designated statistical reporting level. The Disciplinary Fine shall be the greater of

$25,000 or 2.0% of the applicable earned premium at the designated statistical reporting

level.

For reasons a, b, c and d listed above, the premium used in the calculation will correspond to

the basis at which the data in question was reported. If the data in question was reported on

a grouped basis, the premiums used in the calculation will be for the carriers that were

included in the grouping. Conversely, if the data in question was reported on an individual

company basis, the premiums used in the calculation will be those of the individual company.

For reasons e and f above, the premium used in the calculation will be the total premium for

all carriers within the NAIC insurance group.

b. Disciplinary Fine for Reason g:

Carrier groups will be subject to fines on data that remains missing, rejected, or filtered as of

October 1

st

of that review year and each month thereafter until the acceptable threshold is

met.

Any data which remains missing, rejected, or filtered will count against the overall data

expected to be included in the summary for that carrier group. Carrier groups, who have

more than 10 unit statistical reports and more than 1% of their overall data excluded from the

summary, will be fined each month until they reach the 1% or less than 10 unit statistical

report threshold. A carrier group will be subject to a disciplinary fine of $500 per unit

statistical report with a maximum cap of $50,000 fined each month.

Example: If a carrier group has 10,000 units expected to be included in the summary, and

200 units, or 2%, are either missing, rejected or filtered, the carrier would be fined each

month until 100 or fewer units are missing, rejected or filtered.

c. Disciplinary Fine for Reason h:

Such fine will be calculated in the same manner as Disciplinary Fines stemming from reasons

a through d listed above and such fines will not require a written warning letter.

3. Disciplinary Fine Notification

The WCRIBMA will send a written warning letter via email at least 10 business days prior to

levying a Disciplinary Fine for any of the above listed reasons. On the same date, the WCRIBMA

will also send a hard copy of the written warning letter via certified mail return receipt.

G. Reporting of Fines to the Massachusetts Division of Insurance

By September 15

th

of each year, the WCRIBMA shall provide the Massachusetts Division of

Insurance a listing by carrier or carrier group of all Timeliness Fines and Data Quality Fines levied

during the course of the year as a result of the Aggregate Financial Data Quality Incentive Program.

If additional Timeliness Fines or Data Quality Fines are levied during the balance of the year, the

WCRIBMA shall provide an updated report.

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013

Part V – Data Quality Compliance Programs Page 8

Additionally, all Disciplinary Fines will be reported to the Division of Insurance by November 15

th

of

each year. If additional Disciplinary Fines are levied during the balance of the year, the WCRIBMA

shall provide an updated report.

H. Appeal of Penalties Levied under the Data Quality Compliance Programs

If the carrier or carrier group (carrier) is subject to a fine, which in the opinion of the carrier is

inappropriate, the carrier may submit a written appeal to the Data Operations Department via email

(DataOperations@wcribma.org

) or to the following address:

Data Operations Department

WCRIBMA

101 Arch Street, 5th Floor

Boston, MA 02110

The written appeal must be submitted by an officer or senior manager of the carrier within twenty (20)

business days of the invoice date on the invoice for the particular fine(s) at issue. The appeal should

include copies of the relevant invoice(s), all pertinent written communications and detailed statements

that describe why the carrier thinks the fine(s) is inappropriate. The WCRIBMA will provide the carrier

with its written decision on the carrier’s appeal within twenty (20) business days of its receipt of the

appeal.

If the carrier is not satisfied with the WCRIBMA’s decision, it may appeal to the Commissioner of

Insurance. Such an appeal shall be filed within thirty (30) days of the carrier’s receipt of the

WCRIBMA’s written decision. The carrier should provide the WCRIBMA with a copy of any appeal

submitted to the Commissioner of Insurance.

PART VI

APPENDICES

APPENDIX I

EXTRAORDINARY LOSS

EVENT TABLE

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix I – ELE Table

Part VI – Appendices Page 1

PART VI - APPENDICES

APPENDIX I – EXTRAORDINARY LOSS EVENT TABLE

Extraordinary Loss Event

Catastrophe

Number

Event Description Accident Dates

48

World Trade

Center Attacks

Events of September 11, 2001

attacks

9/11/2001 – 9/14/2001

87

World Trade

Center Attacks

Rescue, recovery, and clean-up

efforts related to September 11, 2001

at the World Trade Center site

9/11/2001 – 9/12/2002

PART VI

APPENDICES

APPENDIX II

STATISTICAL CLASS CODES

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: January 1, 2015

Distributed: December, 2014 Appendix II – Statistical Class Codes

Part VI – Appendices Page 1

APPENDIX II – STATISTICAL CLASS CODES

Code

Phraseology

Premiums

Assumed

to be a

Positive

Value

Subject to

Experience

Mod.

How is the

Exposure

Expressed

Can

Losses

be Coded

to this

Class

0032 Loss Constant Yes No Blank No

0059

Occupational Disease-

Abrasive/Sand Blast

Yes Yes Payroll Yes

0063 Premium Discount – Type A No No Blank No

0064 Premium Discount – Type B No No Blank No

0065 Occupational Disease-Steel Yes Yes Payroll Yes

0066

Occupational Disease-Non

Ferrous Metals

Yes Yes Payroll Yes

0067 Occupational Disease-Iron Yes Yes Payroll Yes

0277 All Risk Adjustment Program Yes No Blank No

0771

Non Ratable Element

Explosives or Ammunition

MFG: NOC & DR

Yes No Payroll No

0887

Premium Credit for Scheduled

Rating Plan-Subject to

Experience Rating

No Yes Blank No

0900 Expense Constant Yes No Blank No

0930

Additional Premium – Waiver

of Subrogation

Yes Yes Blank No

0931 Short Rate Penalty Premium Yes No Blank No

0990 Risk Minimum Premium Yes No Blank No

1111 No Massachusetts Exposure

Must be

Zero

No Blank No

7445

Non Ratable Element – Air

Carrier – Other Flying Crew-NR

Yes No Payroll No

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix II – Statistical Class Codes

Part VI – Appendices Page 2

Code

Phraseology

Premiums

Assumed

to be a

Positive

Value

Subject to

Experience

Mod.

How is the

Exposure

Expressed

Can

Losses

be Coded

to this

Class

7453

Non Ratable Element – Air

Carrier – Commuter Flying

Crew-NR

Yes No Payroll No

9034

Rate Deviation – Not Subject to

Experience Rating

No No Blank No

9037

Rate Deviation – Subject to

Experience Rating

No Yes Blank No

9046

Construction Class Premium

Adjustment

No No Blank No

9129

Former Self-Insured Rating

Plan Deposit

Yes No Blank No

9136

Former Self-Insured

Insurance Charge

Yes No Blank No

9663

Large Deductible Adjustment-

Not Subject to Experience

Rating

No No Blank No

9664

Deductible Adjustment-

Subject to Experience Rating

No Yes Blank No

9721

Carrier Filed Premium Credit-

Subject to Experience Rating

No Yes Blank No

9722

Carrier Filed Premium Credit-

Not Subject to Experience

Rating

No No Blank No

9723

Carrier Filed Premium Debit-

Subject to Experience Rating

Yes Yes Blank No

9724

Carrier Filed Premium Debit-

Not Subject to Experience

Rating

Yes No Blank No

9740

Terrorism Insurance Program

(Certified Acts of Terrorism)

Premiums

Yes No Blank No

9803

Employers Liability

100/100/1,000

Yes Yes Blank No

9804

Employers Liability

100/100/2,500

Yes Yes Blank No

9805

Employers Liability

100/100/5,000

Yes Yes Blank No

9806

Employers Liability

100/100/10,000

Yes Yes Blank No

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix II – Statistical Class Codes

Part VI – Appendices Page 3

Code

Phraseology

Premiums

Assumed

to be a

Positive

Value

Subject to

Experience

Mod.

How is the

Exposure

Expressed

Can

Losses

be Coded

to this

Class

9807

Employers Liability

500/500/500

Yes Yes Blank No

9808

Employers Liability

500/500/1,000

Yes Yes Blank No

9809

Employers Liability

500/500/2,500

Yes Yes Blank No

9810

Employers Liability

500/500/5,000

Yes Yes Blank No

9811

Employers Liability

500/500/10,000

Yes Yes Blank No

9812

Employers Liability

1,000/1,000/1,000

Yes Yes Blank No

9813

Employers Liability

1,000/1,000/2,500

Yes Yes Blank No

9814

Employers Liability

1,000/1,000/5,000

Yes Yes Blank No

9815

Employers Liability

1,000/1,000/10,000

Yes Yes Blank No

9816 Employers Liability Yes Yes Blank No

9848

Employers Liability

Minimum Premium

Yes Yes Blank No

9849

Admiralty/FELA Balance

Minimum

Yes No Blank No

9880

Qualified Loss Management

Program Credit

No No Blank No

9884 Merit Rating Unity Must be zero No Blank No

9885 Merit Rating Credit No No Blank No

9886 Merit Rating Debit Yes No Blank No

9887

Premium Credit for Scheduled

Rating Plan-Not Subject to

Experience Rating

No No Blank No

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix II – Statistical Class Codes

Part VI – Appendices Page 4

Code

Phraseology

Premiums

Assumed

to be a

Positive

Value

Subject to

Experience

Mod.

How is the

Exposure

Expressed

Can

Losses

be Coded

to this

Class

9985

Atomic Energy: Radiation

Exposure NOC

Yes No Blank No

PART VI

APPENDICES

APPENDIX III

PENSION TABLES

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: April 1, 2015

Distributed: January, 2015 Appendix III – Pension Tables

Part VI – Appendices Page 1

APPENDIX III – PENSION TABLES

Table IE-398

Pension Table - Surviving Spouse - Fatal Claims

(for Claims after December 23, 1991 Excluding Claims Incurred Under USL&HW Act (with Escalation))

Age at

Widowhood

ᾱ

(x)

(x) + 1

(x) + 2

(x) + 3

(x) + 4

(x) + 5

(x) + 6

(x) + 7

(x) + 8

(x) + 9

(x)+10

16

19.069

19.213

20.036

19.911

20.729

21.368

21.691

22.035

22.401

22.791

23.207

17

19.319

19.478

20.328

20.216

21.063

21.730

22.077

22.446

22.839

23.258

23.645

18

19.585

19.761

20.639

20.542

21.420

22.116

22.488

22.883

23.305

23.695

24.053

19

19.868

20.062

20.970

20.888

21.799

22.527

22.925

23.349

23.742

24.102

24.429

20

20.169

20.382

21.322

21.256

22.202

22.963

23.390

23.785

24.148

24.478

24.773

21

20.755

20.980

21.912

21.795

22.703

23.427

23.825

24.190

24.522

24.820

25.082

22

21.322

21.555

22.479

22.309

23.176

23.861

24.229

24.563

24.863

25.128

25.357

23

21.867

22.108

23.019

22.795

23.620

24.265

24.601

24.903

25.170

25.401

25.596

24

22.387

22.634

23.531

23.252

24.032

24.635

24.939

25.207

25.441

25.638

25.799

25

22.881

23.132

24.012

23.677

24.412

24.971

25.242

25.477

25.676

25.838

25.965

26

23.347

23.600

24.462

24.071

24.757

25.273

25.509

25.710

25.874

26.002

26.094

27

23.782

24.036

24.877

24.430

25.067

25.538

25.740

25.906

26.035

26.128

26.185

28

24.185

24.439

25.256

24.754

25.342

25.767

25.934

26.065

26.159

26.217

26.240

29

24.556

24.808

25.600

25.042

25.579

25.959

26.091

26.186

26.246

26.269

26.257

30

24.891

25.140

25.906

25.293

25.780

26.114

26.210

26.270

26.295

26.284

26.239

31

25.192

25.436

26.174

25.508

25.943

26.231

26.292

26.317

26.307

26.263

26.184

32

25.456

25.694

26.403

25.684

26.069

26.310

26.336

26.327

26.283

26.205

26.094

33

25.683

25.915

26.593

25.823

26.156

26.352

26.344

26.300

26.223

26.113

25.971

34

25.874

26.097

26.743

25.924

26.206

26.357

26.315

26.238

26.128

25.987

25.814

35

26.026

26.241

26.855

25.987

26.220

26.327

26.251

26.141

26.000

25.828

25.626

36

26.142

26.346

26.927

26.013

26.197

26.261

26.152

26.011

25.839

25.637

25.406

37

26.220

26.413

26.960

26.003

26.139

26.160

26.019

25.848

25.646

25.416

25.157

38

26.261

26.442

26.956

25.958

26.046

26.026

25.855

25.654

25.423

25.164

24.878

39

26.266

26.434

26.914

25.877

25.920

25.860

25.659

25.429

25.170

24.884

24.571

40

26.235

26.391

26.836

25.763

25.761

25.663

25.433

25.175

24.888

24.576

24.238

41

26.170

26.312

26.723

25.616

25.572

25.437

25.178

24.892

24.579

24.242

23.880

42

26.070

26.198

26.576

25.438

25.352

25.180

24.894

24.582

24.244

23.883

23.498

43

25.938

26.052

26.396

25.229

25.103

24.896

24.584

24.246

23.885

23.500

23.093

44

25.774

25.873

26.185

24.991

24.825

24.585

24.247

23.886

23.502

23.095

22.666

45

25.580

25.664

25.942

24.724

24.521

24.248

23.887

23.503

23.096

22.667

22.218

46

25.356

25.425

25.670

24.429

24.191

23.888

23.503

23.096

22.667

22.218

21.751

47

25.103

25.155

25.368

24.108

23.836

23.504

23.097

22.668

22.219

21.751

21.268

48

24.822

24.858

25.039

23.763

23.458

23.097

22.668

22.219

21.752

21.268

20.770

49

24.515

24.534

24.684

23.393

23.057

22.668

22.219

21.752

21.268

20.771

20.261

50

24.181

24.184

24.303

23.000

22.633

22.219

21.752

21.268

20.771

20.261

19.742

51

23.823

23.808

23.897

22.582

22.188

21.752

21.268

20.771

20.261

19.742

19.215

52

23.440

23.408

23.465

22.143

21.724

21.268

20.771

20.261

19.742

19.215

18.681

53

23.033

22.983

23.011

21.685

21.244

20.771

20.261

19.742

19.215

18.681

18.140

54

22.605

22.536

21.209

20.749

20.261

19.742

19.215

18.681

18.140

17.593

55

22.157

22.070

22.044

20.719

20.243

19.742

19.215

18.681

18.140

17.593

17.041

56

21.691

21.586

21.535

20.216

19.726

19.215

18.681

18.140

17.593

17.041

16.486

57

21.208

21.086

21.013

19.703

19.201

18.681

18.140

17.593

17.041

16.486

15.930

58

20.711

20.574

20.480

19.181

18.668

18.140

17.593

17.041

16.486

15.930

15.373

59

20.202

20.050

19.937

18.650

18.128

17.593

17.041

16.486

15.930

15.373

14.816

60

19.683

19.517

19.386

18.112

17.582

17.041

16.486

15.930

15.373

14.816

14.257

61

19.154

18.975

18.826

17.568

17.031

16.486

15.930

15.373

14.816

14.257

13.700

62

18.618

18.425

18.260

17.019

16.477

15.930

15.373

14.816

14.257

13.700

13.144

63

18.075

17.869

17.689

16.467

15.922

15.373

14.816

14.257

13.700

13.144

12.592

64

17.527

17.308

17.114

15.913

15.366

14.816

14.257

13.700

13.144

12.592

12.044

65

16.975

16.744

16.538

15.358

14.809

14.257

13.700

13.144

12.592

12.044

11.502

66

16.420

16.179

15.960

14.802

14.251

13.700

13.144

12.592

12.044

11.502

10.965

67

15.863

15.612

15.382

14.245

13.694

13.144

12.592

12.044

11.502

10.965

10.432

68

15.307

15.046

14.803

13.689

13.140

12.592

12.044

11.502

10.965

10.432

9.906

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: April 1, 2015

Distributed: January, 2015 Appendix III – Pension Tables

Part VI – Appendices Page 2

APPENDIX III – PENSION TABLES

Table IE-398

Pension Table - Surviving Spouse - Fatal Claims

(for Claims after December 23, 1991 Excluding Claims Incurred Under USL&HW Act (with Escalation))

Age at

Widowhood

ᾱ

(x)

(x) + 1

(x) + 2

(x) + 3

(x) + 4

(x) + 5

(x) + 6

(x) + 7

(x) + 8

(x) + 9

(x)+10

69

14.750

14.478

14.225

13.136

12.588

12.044

11.502

10.965

10.432

9.906

9.390

70

14.193

13.912

13.649

12.585

12.041

11.502

10.965

10.432

9.906

9.390

8.885

71

13.636

13.348

13.076

12.038

11.500

10.965

10.432

9.906

9.390

8.885

8.389

72

13.082

12.786

12.508

11.497

10.962

10.432

9.906

9.390

885 8.

8.389

7.902

73

12.531

12.229

11.945

10.961

10.430

9.906

9.390

8.885

8.389

7.902

7.428

74

11.984

11.678

11.387

10.429

9.905

9.390

8.885

8.389

7.902

7.428

6.972

75

11.443

11.131

10.834

9.904

9.389

8.885

8.389

7.902

7.428

6.972

6.531

76

10.906

10.589

10.288

9.389

8.884

8.389

7.902

7.428

6.972

6.531

6.109

77

10.375

10.054

9.752

8.884

8.388

7.902

7.428

6.972

6.531

6.109

5.709

78

9.850

9.529

9.226

8.388

7.901

7.428

6.972

6.531

6.109

5.709

5.330

79

9.334

9.014

8.711

7.901

7.428

6.972

6.531

6.109

5.709

5.330

4.972

80

8.830

8.509

8.204

7.428

6.971

6.531

6.109

5.709

5.330

4.972

4.635

81

8.334

8.013

7.712

6.971

6.531

6.109

5.709

5.330

4.972

4.635

4.318

82

7.848

7.531

7.236

6.531

6.109

5.709

5.330

4.972

4.635

4.318

4.022

83

7.376

7.065

6.778

6.109

5.709

5.330

4.972

4.635

4.318

4.022

3.746

84

6.920

6.616

6.338

5.709

5.331

4.972

4.635

4.318

4.022

3.746

3.490

85

6.480

6.186

5.923

5.331

4.972

4.635

4.318

4.022

3.746

3.490

3.253

86

6.059

5.779

5.529

4.972

4.635

4.318

4.022

3.746

3.490

3.253

3.036

87

5.660

5.393

5.156

4.635

4.318

4.022

3.746

3.490

3.253

3.036

2.837

88

5.282

5.028

4.804

4.318

4.022

3.746

3.490

3.253

3.036

2.837

2.657

89

4.925

4.684

4.475

4.022

3.746

3.490

3.253

3.036

2.837

2.657

2.496

90

4.589

4.362

4.166

3.746

3.490

3.253

3.036

2.837

2.657

2.496

2.354

91

4.273

4.060

3.879

3.490

3.253

3.036

2.837

2.657

2.496

2.354

2.218

92

3.979

3.779

3.612

3.253

3.036

2.837

2.657

2.496

2.354

2.218

2.087

93

3.704

3.518

3.366

3.036

2.837

2.657

2.496

2.354

2.218

2.087

1.962

94

3.449

3.278

3.140

2.837

2.657

2.496

2.354

2.218

2.087

1.962

1.841

95

3.214

3.057

2.933

2.657

2.496

2.354

2.218

2.087

1.962

1.841

1.727

96

2.999

2.855

2.746

2.496

2.354

2.218

2.087

1.962

1.841

1.727

1.617

97

2.802

2.672

2.578

2.354

2.218

2.087

1.962

1.841

1.727

1.617

1.511

98

2.623

2.508

2.430

2.218

2.087

1.962

1.841

1.727

1.617

1.511

1.411

99

2.463

2.364

2.288

2.087

1.962

1.841

1.727

1.617

1.511

1.411

1.315

100

2.322

2.226

2.152

1.962

1.841

1.727

1.617

1.511

1.411

1.315

1.223

101

2.187

2.093

2.021

1.841

1.727

1.617

1.511

1.411

1.315

1.223

1.135

102

2.058

1.966

1.896

1.727

1.617

1.511

1.411

1.315

1.223

1.135

1.052

103

1.934

1.844

1.777

1.617

1.511

1.411

1.315

1.223

1.135

1.052

0.972

104

1.816

1.728

1.662

1.511

1.411

1.315

1.223

1.135

1.052

0.972

0.896

Notes:

Source: Based on the 2009 United States Life Table for the Female Population

Remarriage probabilities based on the 1997 US Railroad Retirement Board Remarriage Table

Annual Rate of Interest = 3.5%

Annual Rate of Escalation after year 2 = 2.0%

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: April 1, 2015

Distributed: January, 2015 Appendix III – Pension Tables

Part VI – Appendices Page 3

Calculation 1st Report 2nd Report 3rd Report

1. Valuation Date

7/2014

7/2015

7/2016

2. Spouse's attained age at date of death

33

3. Duration since date of death (to nearest year), t.

1

2

3

4. Weekly Benefit Payable

$386.67

$396.34

5. Annual Benefit Payable [ = (4) x 52 ]

$20,107

$20,610

Benefits for Spouse beyond the Valuation Date

6. Factor from Table IE-398

27.526

26.593

25.823

7. Present Value of Future Payment [ = (5) x (6) ]

$553,461

$534,700

$532,199

Others

8. Payment since date of death

$28,614

$48,720

$69,224

9. Funeral Allowance, Maximum of $4,000

$4,000

10. Total Incurred Indemnity Loss [ = (7) + (8) + (9) ]

$586,074

$587,421

$605,422

Notes:

• (4): The weekly benefit payment is equal to two-thirds of the average weekly wage of the deceased employee. In no instance shall

said widow/widower, receive less than $110 per week. Additional compensation is paid in the amount of $6 a week for each child

of the deceased employee under the age of eighteen or over said age and physically or mentally incapacitated from earning, or

over said age and a full time student qualified for exemption as a dependent, except that no additional compensation for the

benefits of the children of the employee shall be payable when combined with the compensation due to the spouse that would

allow the widow(er) an amount in excess of $150 per week. (MGL c. 152, Sec 31)

Weekly Benefit Payments are subjected to "Cost of Living Adjustments" (COLA):

Any person receiving or entitled to receive benefits under the provisions of Section 31 or 34A whose benefits are based on a

date of personal injury at least 24 months prior to the review date shall have his weekly benefit adjusted subject to:

o The annual change in the Adjusted Benefit shall not exceed the minimum of:

 The increase in the State Average Weekly Wage (SAWW)

 The increase in the Northeastern region CPI for all urban consumers

 5%

o In no instance shall the adjusted benefit be greater than "three times the base benefit."

Benefit Reevaluation Date

2/5/2013

10/1/2015

COLA Adjustment Factor

1.0250

Adjusted Benefit

$386.67

$396.34

Base Benefit

1

st

Escalated Benefit

Supplemental Benefit

$9.67

Weekly Benefit

$386.67

$396.34*

(Base Benefit + Supplemental Benefit)

Notes:

 *$396.34 = $386.67 x max(1.0250,1.0), subject to a maximum of $1160 (3 times the $386.67 base benefit)

 If the adjusted benefit is larger than the base benefit, the difference shall be termed the supplemental benefit.

 No increase in benefits shall be payable which would reduce any benefits the recipient is receiving pursuant to

federal social security law.

 For purposes of this example, the COLA Adjustment Factor has been arbitrarily selected. The proper amounts

of adjustments to compensation required under §34B are published by the DIA each October.

• (6): 1st Report factor is from the 9/1/2011 Pension Table, 2nd Report factor is from the 4/1/2015 Pension Table, 3rd Report is

from the 4/1/2015 Pension Table.

Example - Fatal Claim - Spouse & One Child

Usage of: Surviving Spouse's Pension Table (Table IE-398)

Calculation of incurred loss to be reported when benefits are payable to a surviving spouse until death or

remarriage, due to a fatal injury occurring after December 23, 1991.

Accident Date:

2/5/2013

Policy Effective Date:

1/1/2013

Date of Death:

2/5/2013

Spouse's Birthdate:

7/20/1979

Weekly Wages:

$580

Child's Birthdate:

10/15/2003

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: April 1, 2015

Distributed: January, 2015 Appendix III – Pension Tables

Part VI – Appendices Page 4

Table IIE-398

Pension Table – Other than Surviving Spouse - Fatal Claims

(for Claims after December 23, 1991 Excluding Claims Incurred Under USL&HW Act (with Escalation))

Age

ᾱ

(x)

(x) + 1

(x) + 2

(x) + 3

(x) + 4

(x) + 5

(x) + 6

(x) + 7

(x) + 8

(x) + 9

(x)+10

0

44.171

44.989

45.565

43.425

43.053

42.673

42.287

41.895

41.497

41.092

40.681

1

44.227

44.776

45.338

43.202

42.824

42.441

42.051

41.655

41.252

40.843

40.428

2

44.015

44.551

45.102

42.969

42.588

42.200

41.806

41.406

40.999

40.587

40.168

3

43.791

44.315

44.856

42.729

42.343

41.952

41.554

41.149

40.738

40.322

39.901

4

43.556

44.070

44.602

42.481

42.091

41.695

41.292

40.884

40.470

40.051

39.628

5

43.312

43.817

44.339

42.224

41.830

41.430

41.023

40.611

40.194

39.774

39.351

6

43.060

43.555

44.068

41.959

41.561

41.156

40.746

40.331

39.913

39.492

39.068

7

42.800

43.285

43.788

41.686

41.283

40.874

40.461

40.045

39.626

39.205

38.780

8

42.531

43.007

43.499

41.404

40.997

40.586

40.171

39.754

39.334

38.912

38.486

9

42.254

42.719

43.200

41.113

40.704

40.291

39.876

39.458

39.037

38.614

38.187

10

41.967

42.423

42.894

40.816

40.405

39.991

39.575

39.156

38.734

38.309

37.880

11

41.673

42.118

42.580

40.512

40.100

39.686

39.269

38.848

38.425

37.998

37.568

12

41.369

41.805

42.259

40.204

39.791

39.375

38.956

38.534

38.109

37.681

37.248

13

41.059

41.487

41.933

39.889

39.475

39.058

38.638

38.214

37.787

37.356

36.921

14

40.742

41.163

41.601

39.569

39.154

38.735

38.313

37.887

37.458

37.024

36.585

15

40.420

40.833

41.264

39.243

38.826

38.405

37.981

37.553

37.121

36.683

36.239

16

40.093

40.497

40.920

38.911

38.491

38.069

37.642

37.212

36.775

36.332

35.883

17

39.760

40.156

40.569

38.572

38.151

37.725

37.296

36.861

36.419

35.971

35.516

18

39.420

39.807

40.211

38.227

37.803

37.374

36.941

36.500

36.053

35.599

35.138

19

39.075

39.452

39.847

37.874

37.447

37.014

36.575

36.129

35.676

35.217

34.751

20

38.723

39.091

39.475

37.514

37.082

36.644

36.199

35.747

35.289

34.824

34.353

21

38.364

38.722

39.096

37.145

36.707

36.264

35.813

35.355

34.892

34.422

33.945

22

37.998

38.346

38.707

36.765

36.322

35.873

35.416

34.953

34.484

34.009

33.528

23

37.625

37.960

38.308

36.376

35.927

35.471

35.009

34.541

34.067

33.586

33.100

24

37.243

37.565

37.898

35.976

35.521

35.060

34.593

34.119

33.640

33.154

32.662

25

36.851

37.159

37.477

35.566

35.106

34.639

34.166

33.687

33.203

32.712

32.215

26

36.449

36.742

37.046

35.147

34.681

34.208

33.730

33.246

32.756

32.260

31.758

27

36.038

36.316

36.605

34.717

34.246

33.768

33.285

32.795

32.300

31.798

31.292

28

35.616

35.880

36.154

34.279

33.802

33.319

32.830

32.335

31.834

31.328

30.817

29

35.185

35.434

35.694

33.831

33.348

32.860

32.365

31.865

31.360

30.849

30.333

30

34.745

34.980

35.224

33.374

32.886

32.392

31.892

31.387

30.877

30.361

29.841

31

34.296

34.516

34.745

32.908

32.415

31.915

31.410

30.900

30.385

29.866

29.342

32

33.839

34.043

34.257

32.434

31.935

31.430

30.921

30.406

29.887

29.363

28.836

33

33.373

33.562

33.760

31.951

31.447

30.938

30.423

29.904

29.381

28.854

28.324

34

32.899

33.073

33.255

31.461

30.952

30.437

29.919

29.396

28.869

28.339

27.806

35

32.417

32.575

32.742

30.963

30.449

29.931

29.408

28.881

28.351

27.819

27.283

36

31.927

32.070

32.222

30.458

29.940

29.418

28.891

28.361

27.829

27.294

26.756

37

31.431

31.559

31.695

29.948

29.425

28.899

28.369

27.837

27.302

26.764

26.224

38

30.927

31.040

31.161

29.431

28.905

28.375

27.843

27.308

26.771

26.230

25.688

39

30.418

30.516

30.622

28.909

28.380

27.848

27.313

26.776

26.235

25.693

25.148

40

29.904

29.987

30.078

28.383

27.851

27.317

26.779

26.239

25.697

25.152

24.607

41

29.384

29.453

29.530

27.854

27.319

26.782

26.242

25.699

25.155

24.610

24.064

42

28.860

28.914

28.978

27.321

26.784

26.244

25.701

25.157

24.612

24.066

23.519

43

28.332

28.373

28.423

26.785

26.245

25.703

25.159

24.613

24.067

23.520

22.972

44

27.800

27.829

27.864

26.246

25.704

25.159

24.614

24.068

23.521

22.973

22.423

45

27.267

27.281

27.303

25.704

25.160

24.615

24.069

23.522

22.974

22.424

21.871

46

26.730

26.738

25.161

24.615

24.069

23.523

22.974

22.424

21.872

21.317

47

26.190

26.177

26.172

24.616

24.070

23.523

22.975

22.425

21.872

21.317

20.760

48

25.648

25.622

25.605

24.070

23.523

22.975

22.425

21.872

21.317

20.760

20.201

49

25.104

25.066

25.036

23.523

22.975

22.425

21.872

21.317

20.760

20.201

19.642

50

24.558

24.509

24.467

22.975

22.425

21.872

21.317

20.760

20.202

19.642

19.081

51

24.013

23.951

23.897

22.425

21.872

21.317

20.760

20.202

19.642

19.081

18.520

52

23.466

23.392

23.324

21.872

21.317

20.760

20.202

19.642

19.081

18.520

17.958

53

22.918

22.831

22.749

21.317

20.760

20.202

19.642

19.081

18.520

17.958

17.396

54

22.368

22.267

22.171

20.760

20.202

19.642

19.081

18.520

17.958

17.396

16.834

55

21.815

21.701

21.591

20.202

19.642

19.081

18.520

17.958

17.396

16.834

16.273

56

21.260

21.132

21.009

19.642

19.081

18.520

17.958

17.396

16.834

16.273

15.715

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: April 1, 2015

Distributed: January, 2015 Appendix III – Pension Tables

Part VI – Appendices Page 5

Table IIE-398

Pension Table – Other than Surviving Spouse - Fatal Claims

(for Claims after December 23, 1991 Excluding Claims Incurred Under USL&HW Act (with Escalation))

Age

ᾱ

(x)

(x) + 1

(x) + 2

(x) + 3

(x) + 4

(x) + 5

(x) + 6

(x) + 7

(x) + 8

(x) + 9

(x)+10

57

20.703

20.562

20.427

19.081

18.520

17.958

17.396

16.834

16.273

15.715

15.161

58

20.144

19.991

19.843

18.520

17.958

17.396

16.834

16.273

15.715

15.161

14.610

59

19.585

19.419

19.259

17.958

17.396

16.834

16.273

15.715

15.161

14.610

14.062

60

19.024

18.846

18.674

17.396

16.834

16.273

15.715

15.161

14.610

14.062

13.517

61

18.463

18.273

18.089

16.834

16.273

15.715

15.161

14.610

14.062

13.517

12.973

62

17.901

17.700

17.504

16.273

15.715

15.161

14.610

14.062

13.517

12.973

12.434

63

17.339

17.126

16.920

15.715

15.161

14.610

14.062

13.517

12.973

12.434

11.900

64

16.777

16.555

16.339

15.161

14.610

14.062

13.517

12.973

12.434

11.900

11.372

65

16.217

15.985

15.762

14.610

14.062

13.517

12.973

12.434

11.900

11.372

10.853

66

15.659

15.420

15.189

14.062

13.517

12.973

12.434

11.900

11.372

10.853

10.339

67

15.105

14.858

14.619

13.517

12.973

12.434

11.900

11.372

10.853

10.339

9.832

68

14.554

14.299

14.050

12.973

12.434

11.900

11.372

10.853

10.339

9.832

9.334

69

14.006

13.742

13.485

12.434

11.900

11.372

10.853

10.339

9.832

9.334

8.847

70

13.461

13.188

12.924

11.900

11.372

10.853

10.339

9.832

9.334

8.847

8.372

71

12.918

12.638

12.367

11.372

10.853

10.339

9.832

9.334

8.847

8.372

7.907

72

12.379

12.093

11.818

10.853

10.339

9.832

9.334

8.847

8.372

7.907

7.452

73

11.844

11.555

11.277

10.339

9.832

9.334

8.847

8.372

7.907

7.452

7.010

74

11.317

11.024

10.742

9.832

9.334

8.847

8.372

7.907

7.452

7.010

6.583

75

10.798

10.500

10.215

9.334

8.847

8.372

7.907

7.452

7.010

6.583

6.172

76

10.284

9.984

9.697

8.847

8.372

7.907

7.452

7.010

6.583

6.172

5.783

77

9.778

9.476

9.190

8.372

7.907

7.452

7.010

6.583

6.172

5.783

5.413

78

9.280

8.979

8.695

7.907

7.452

7.010

6.583

6.172

5.783

5.413

5.063

79

8.794

8.494

8.210

7.452

7.010

6.583

6.172

5.783

5.413

5.063

4.732

80

8.319

8.020

7.737

7.010

6.583

6.172

5.783

5.413

5.063

4.732

4.421

81

7.854

7.555

7.277

6.583

6.172

5.783

5.413

5.063

4.732

4.421

4.129

82

7.400

7.105

6.833

6.172

5.783

5.413

5.063

4.732

4.421

4.129

3.855

83

6.959

6.670

6.405

5.783

5.413

5.063

4.732

4.421

4.129

3.855

3.600

84

6.533

6.251

6.000

5.413

5.063

4.732

4.421

4.129

3.855

3.600

3.364

85

6.122

5.854

5.615

5.063

4.732

4.421

4.129

3.855

3.600

3.364

3.144

86

5.734

5.477

5.250

4.732

4.421

4.129

3.855

3.600

3.364

3.144

2.942

87

5.365

5.121

4.906

4.421

4.129

3.855

3.600

3.364

3.144

2.942

2.756

88

5.016

4.784

4.582

4.129

3.855

3.600

3.364

3.144

2.942

2.756

2.586

89

4.686

4.466

4.277

3.855

3.600

3.364

3.144

2.942

2.756

2.586

2.432

90

4.376

4.169

3.993

3.600

3.364

3.144

2.942

2.756

2.586

2.432

2.292

91

4.085

3.890

3.728

3.364

3.144

2.942

2.756

2.586

2.432

2.292

2.159

92

3.813

3.631

3.481

3.144

2.942

2.756

2.586

2.432

2.292

2.159

2.030

93

3.560

3.390

3.253

2.942

2.756

2.586

2.432

2.292

2.159

2.030

1.907

94

3.324

3.167

3.042

2.756

2.586

2.432

2.292

2.159

2.030

1.907

1.790

95

3.106

2.962

2.849

2.586

2.432

2.292

2.159

2.030

1.907

1.790

1.677

96

2.906

2.773

2.672

2.432

2.292

2.159

2.030

1.907

1.790

1.677

1.569

97

2.721

2.600

2.511

2.292

2.159

2.030

1.907

1.790

1.677

1.569

1.466

98

2.553

2.443

2.366

2.159

2.030

1.907

1.790

1.677

1.569

1.466

1.367

99

2.400

2.302

2.227

2.030

1.907

1.790

1.677

1.569

1.466

1.367

1.273

100

2.261

2.166

2.093

1.907

1.790

1.677

1.569

1.466

1.367

1.273

1.183

101

2.129

2.036

1.965

1.790

1.677

1.569

1.466

1.367

1.273

1.183

1.098

102

2.002

1.911

1.842

1.677

1.569

1.466

1.367

1.273

1.183

1.098

1.016

103

1.881

1.792

1.725

1.569

1.466

1.367

1.273

1.183

1.098

1.016

0.938

104

1.764

1.678

1.613

1.466

1.367

1.273

1.183

1.098

1.016

0.938

0.864

Notes:

Source: Based on the 2009 United States Life Table for the Total Population

Annual Rate of Interest = 3.5%

Annual Rate of Escalation after year 2 = 2.0%

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: April 1, 2015

Distributed: January, 2015 Appendix III – Pension Tables

Part VI – Appendices Page 6

Calculation 1st Report 2nd Report 3rd Report

1. Valuation Date

7/2014

7/2015

7/2016

2. Dependent’s attained age at date of death

33

3. Duration since date of death (to nearest year), t.

1

2

3

4. Weekly Benefit Payable

$80.00

$82.00

5. Annual Benefit Payable [ = (4) x 52 ]

$4,160

$4,264

Benefits for Dependent beyond the Valuation Date

6. Factor from Table IIE-398

35.668

33.760

31.951

7. Present Value of Future Payment [ = (5) x (6) ]

$148,379

$140,442

$136,240

Others

8. Payment since Date of Death

$5,920

$10,080

$14,322

9. Funeral Allowance, Maximum of $4,000

$1,500

10. Total Incurred Indemnity Loss [ = (7) + (8) + (9) ]

$155,799

$152,022

$152,062

Notes:

• (4): The weekly benefit payment should not be more than two-thirds of the average weekly wage of the deceased employee or more

than $80 a week; provided, however, that if there is more than one such dependent, the total amount payable shall not exceed the

weekly amount which is, or would be payable to a surviving spouse of the deceased employee. (M.G.L c.152, Sec 31)

Weekly Benefit Payments are subjected to "Cost of Living Adjustments" (COLA):

Any person receiving or entitled to receive benefits under the provisions of Section 31 or 34A whose benefits are based on a date of

personal injury at least 24 months prior to the review date shall have his weekly benefit adjusted subject to:

o The annual change in the Adjusted Benefit shall not exceed the minimum of:

 The increase in the State Average Weekly Wage (SAWW)

 The increase in the Northeastern region CPI for all urban consumers

 5%

o In no instance shall the adjusted benefit be greater than "three times the base benefit."

Benefit Reevaluation Date

2/5/2013

10/1/2015

COLA Adjustment Factor

1.0250

Adjusted Benefit

$80.00

$82.00

Base Benefit

1

st

Escalated Benefit

Supplemental Benefit

$2.00

Weekly Benefit

$80.00

$82.00*

(Base Benefit + Supplemental Benefit)

Notes:

 * $82.00 = $80.00 x max(1.0250,1.0), to a maximum of $387 (2/3 average weekly wage of deceased employee)

 If the adjusted benefit is larger than the base benefit, the difference shall be termed the supplemental benefit.

 No increase in benefits shall be payable which would reduce any benefits the recipient is receiving pursuant to federal

social security law.

 For purposes of this example, the COLA Adjustment Factor has been arbitrarily selected. The proper amounts of

adjustments to compensation required under §34B are published by the DIA each October.

• (6): 1st Report factor is from the 9/1/2011 Pension Table, 2nd Report factor is from the 4/1/2015 Pension Table, 3rd Report is from

the 4/1/2015 Pension Table.

Example - Fatal Claim – Other than Spouse

Usage of: Other than Surviving Spouse's Pension Table (Table IIE-398)

Calculation of incurred loss to be reported when benefits are payable to a dependent other than a surviving

spouse due to a fatal injury occurring after December 23, 1991.

Accident Date:

2/5/2013

Policy Effective Date:

1/1/2013

Date of Death:

2/5/2013

Dependent’s Birthdate:

7/20/1979

Weekly Wages:

$580

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: April 1, 2015

Distributed: January, 2015 Appendix III – Pension Tables

Part VI – Appendices Page 7

Table IIIEM-398 – Male

Pension Table – Permanent Total Claimants

(for Claims after December 23, 1991 Excluding Claims Incurred Under USL&HW Act (with Escalation))

Age at

Accident

Date

ᾱ

(x)

(x) + 1

(x) + 2

(x) + 3

(x) + 4

(x) + 5

(x) + 6

(x) + 7

(x) + 8

(x) + 9

(x)+10

0

40.239

41.252

41.741

39.736

39.344

38.942

38.534

38.118

37.695

37.264

36.825

1

40.530

40.993

41.461

39.457

39.057

38.650

38.235

37.814

37.385

36.948

36.503

2

40.273

40.715

41.166

39.165

38.760

38.347

37.927

37.500

37.065

36.622

36.173

3

39.996

40.422

40.859

38.865

38.453

38.035

37.609

37.176

36.735

36.288

35.838

4

39.706

40.117

40.542

38.554

38.138

37.713

37.281

36.842

36.396

35.948

35.500

5

39.403

39.802

40.215

38.234

37.811

37.381

36.943

36.499

36.052

35.606

35.166

6

39.090

39.478

39.877

37.904

37.475

37.038

36.596

36.150

35.705

35.268

34.835

7

38.768

39.143

39.530

37.564

37.128

36.687

36.243

35.800

35.363

34.932

34.505

8

38.437

38.798

39.171

37.213

36.773

36.330

35.888

35.453

35.023

34.598

34.177

9

38.095

38.443

38.802

36.854

36.412

35.971

35.537

35.109

34.685

34.265

33.849

10

37.742

38.077

38.424

36.489

36.049

35.616

35.189

34.766

34.348

33.933

33.522

11

37.380

37.702

38.039

36.121

35.690

35.264

34.842

34.425

34.012

33.602

33.197

12

37.009

37.321

37.653

35.758

35.333

34.913

34.497

34.085

33.676

33.272

32.871

13

36.632

36.938

37.271

35.398

34.978

34.563

34.152

33.745

33.342

32.942

32.543

14

36.252

36.560

36.891

35.039

34.625

34.215

33.808

33.407

33.008

32.610

32.207

15

35.878

36.184

36.513

34.681

34.272

33.867

33.466

33.069

32.671

32.269

31.860

16

35.506

35.810

36.137

34.325

33.920

33.520

33.124

32.728

32.327

31.919

31.503

17

35.135

35.438

35.762

33.969

33.570

33.174

32.779

32.379

31.972

31.557

31.135

18

34.767

35.066

35.388

33.615

33.220

32.826

32.426

32.020

31.606

31.185

30.756

19

34.399

34.696

35.016

33.262

32.868

32.469

32.064

31.651

31.230

30.802

30.369

20

34.033

34.327

34.644

32.905

32.508

32.103

31.690

31.270

30.844

30.411

29.973

21

33.668

33.960

34.270

32.542

32.138

31.726

31.306

30.880

30.448

30.011

29.568

22

33.305

33.589

33.888

32.168

31.757

31.338

30.913

30.481

30.044

29.603

29.156

23

32.939

33.212

33.496

31.785

31.366

30.941

30.510

30.074

29.633

29.186

28.735

24

32.565

32.824

33.093

31.391

30.966

30.535

30.100

29.659

29.213

28.762

28.305

25

32.183

32.427

32.680

30.987

30.557

30.122

29.681

29.236

28.785

28.329

27.866

26

31.790

32.019

32.257

30.576

30.141

29.701

29.255

28.805

28.349

27.887

27.417

27

31.388

31.602

31.826

30.156

29.717

29.272

28.822

28.366

27.904

27.435

26.960

28

30.977

31.177

31.387

29.730

29.286

28.836

28.380

27.919

27.450

26.975

26.494

29

30.559

30.745

30.941

29.297

28.847

28.392

27.930

27.462

26.987

26.507

26.020

30

30.133

30.305

30.487

28.856

28.401

27.940

27.472

26.997

26.517

26.031

25.540

31

29.701

29.859

30.027

28.409

27.947

27.479

27.005

26.525

26.039

25.548

25.053

32

29.262

29.407

29.560

27.953

27.485

27.011

26.531

26.045

25.554

25.059

24.559

33

28.817

28.947

29.084

27.490

27.016

26.535

26.050

25.559

25.064

24.564

24.061

34

28.366

28.480

28.600

27.019

26.539

26.053

25.563

25.068

24.568

24.065

23.559

35

27.907

28.005

28.109

26.541

26.056

25.566

25.070

24.571

24.068

23.562

23.054

36

27.441

27.523

27.612

26.058

25.567

25.072

24.572

24.069

23.564

23.057

22.547

37

26.968

27.035

27.108

25.569

25.074

24.574

24.071

23.565

23.058

22.548

22.036

38

26.489

26.540

26.598

25.074

24.575

24.072

23.566

23.059

22.549

22.036

21.522

39

26.004

26.041

26.083

24.575

24.072

23.567

23.059

22.550

22.037

21.522

21.007

40

25.514

25.536

25.563

24.073

23.567

23.060

22.550

22.037

21.523

21.007

20.492

41

25.020

25.026

25.040

23.567

23.060

22.550

22.038

21.523

21.007

20.492

19.978

42

24.520

24.513

24.514

23.060

22.551

22.038

21.523

21.007

20.492

19.978

19.465

43

24.017

23.998

23.986

22.551

22.038

21.523

21.007

20.492

19.978

19.465

18.953

44

23.512

23.480

23.455

22.038

21.523

21.008

20.492

19.978

19.465

18.953

18.440

45

23.004

22.960

22.922

21.523

21.008

20.492

19.978

19.465

18.953

18.440

17.926

46

22.495

22.437

22.386

21.008

20.492

19.978

19.465

18.953

18.440

17.926

17.412

47

21.982

21.912

21.849

20.492

19.978

19.465

18.953

18.440

17.926

17.412

16.897

48

21.467

21.386

21.313

19.978

19.465

18.953

18.440

17.926

17.412

16.897

16.382

49

20.952

20.860

20.777

19.465

18.953

18.440

17.926

17.412

16.897

16.382

15.867

50

20.437

20.335

20.244

18.953

18.440

17.926

17.412

16.897

16.382

15.867

15.351

51

19.922

19.812

19.710

18.440

17.926

17.412

16.897

16.382

15.867

15.351

14.834

52

19.410

19.290

19.176

17.926

17.412

16.897

16.382

15.867

15.351

14.834

14.316

53

18.898

18.766

18.641

17.412

16.897

16.382

15.867

15.351

14.834

14.316

13.798

54

18.385

18.242

18.106

16.897

16.382

15.867

15.351

14.834

14.316

13.798

13.280

55

17.871

17.717

17.570

16.382

15.867

15.351

14.834

14.316

13.798

13.280

12.766

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: April 1, 2015

Distributed: January, 2015 Appendix III – Pension Tables

Part VI – Appendices Page 8

Table IIIEM-398 – Male

Pension Table – Permanent Total Claimants

(for Claims after December 23, 1991 Excluding Claims Incurred Under USL&HW Act (with Escalation))

Age at

Accident

Date

ᾱ

(x)

(x) + 1

(x) + 2

(x) + 3

(x) + 4

(x) + 5

(x) + 6

(x) + 7

(x) + 8

(x) + 9

(x)+10

56

17.357

17.192

17.034

15.867

15.351

14.834

14.316

13.798

13.280

12.766

12.257

57

16.842

16.667

16.498

15.351

14.834

14.316

13.798

13.280

12.766

12.257

11.754

58

16.327

16.141

15.961

14.834

14.316

13.798

13.280

12.766

12.257

11.754

11.258

59

15.812

15.615

15.423

14.316

13.798

13.280

12.766

12.257

11.754

11.258

10.766

60

15.296

15.087

14.883

13.798

13.280

12.766

12.257

11.754

11.258

10.766

10.277

61

14.779

14.559

14.343

13.280

12.766

12.257

11.754

11.258

10.766

10.277

9.791

62

14.262

14.030

13.805

12.766

12.257

11.754

11.258

10.766

10.277

9.791

9.309

63

13.743

13.502

13.270

12.257

11.754

11.258

10.766

10.277

9.791

9.309

8.834

64

13.226

12.978

12.739

11.754

11.258

10.766

10.277

9.791

9.309

8.834

8.368

65

12.712

12.458

12.216

11.258

10.766

10.277

9.791

9.309

8.834

8.368

7.912

66

12.202

11.945

11.700

10.766

10.277

9.791

9.309

8.834

8.368

7.912

7.465

67

11.700

11.439

11.188

10.277

9.791

9.309

8.834

8.368

7.912

7.465

7.028

68

11.204

10.938

10.679

9.791

9.309

8.834

8.368

7.912

7.465

7.028

6.603

69

10.713

10.439

10.173

9.309

8.834

8.368

7.912

7.465

7.028

6.603

6.192

70

10.224

9.943

9.671

8.834

8.368

7.912

7.465

7.028

6.603

6.192

5.793

71

9.738

9.451

9.176

8.368

7.912

7.465

7.028

6.603

6.192

5.793

5.407

72

9.256

8.966

8.691

7.912

7.465

7.028

6.603

6.192

5.793

5.407

5.034

73

8.781

8.491

8.217

7.465

7.028

6.603

6.192

5.793

5.407

5.034

4.672

74

8.316

8.026

7.751

7.028

6.603

6.192

5.793

5.407

5.034

4.672

4.325

75

7.861

7.570

7.297

6.603

6.192

5.793

5.407

5.034

4.672

4.325

3.993

76

7.414

7.125

6.854

6.192

5.793

5.407

5.034

4.672

4.325

3.993

3.691

77

6.978

6.692

6.426

5.793

5.407

5.034

4.672

4.325

3.993

3.691

3.409

78

6.554

6.272

6.011

5.407

5.034

4.672

4.325

3.993

3.691

3.409

3.148

79

6.143

5.865

5.609

5.034

4.672

4.325

3.993

3.691

3.409

3.148

2.910

80

5.745

5.472

5.220

4.672

4.325

3.993

3.691

3.409

3.148

2.910

2.688

81

5.360

5.091

4.843

4.325

3.993

3.691

3.409

3.148

2.910

2.688

2.483

82

4.987

4.722

4.483

3.993

3.691

3.409

3.148

2.910

2.688

2.483

2.294

83

4.626

4.370

4.136

3.691

3.409

3.148

2.910

2.688

2.483

2.294

2.120

84

4.281

4.031

3.823

3.409

3.148

2.910

2.688

2.483

2.294

2.120

1.960

85

3.950

3.724

3.529

3.148

2.910

2.688

2.483

2.294

2.120

1.960

1.814

86

3.650

3.437

3.258

2.910

2.688

2.483

2.294

2.120

1.960

1.814

1.681

87

3.369

3.172

3.009

2.688

2.483

2.294

2.120

1.960

1.814

1.681

1.560

88

3.110

2.929

2.778

2.483

2.294

2.120

1.960

1.814

1.681

1.560

1.451

89

2.873

2.704

2.565

2.294

2.120

1.960

1.814

1.681

1.560

1.451

1.355

90

2.653

2.495

2.368

2.120

1.960

1.814

1.681

1.560

1.451

1.355

1.271

91

2.450

2.303

2.187

1.960

1.814

1.681

1.560

1.451

1.355

1.271

1.192

92

2.263

2.127

2.020

1.814

1.681

1.560

1.451

1.355

1.271

1.192

1.115

93

2.090

1.965

1.868

1.681

1.560

1.451

1.355

1.271

1.192

1.115

1.042

94

1.933

1.817

1.730

1.560

1.451

1.355

1.271

1.192

1.115

1.042

0.971

95

1.788

1.682

1.604

1.451

1.355

1.271

1.192

1.115

1.042

0.971

0.904

96

1.657

1.560

1.491

1.355

1.271

1.192

1.115

1.042

0.971

0.904

0.840

97

1.538

1.450

1.390

1.271

1.192

1.115

1.042

0.971

0.904

0.840

0.780

98

1.431

1.353

1.303

1.192

1.115

1.042

0.971

0.904

0.840

0.780

0.726

99

1.336

1.269

1.220

1.115

1.042

0.971

0.904

0.840

0.780

0.726

0.697

100

1.254

1.189

1.141

1.042

0.971

0.904

0.840

0.780

0.726

0.697

0.675

101

1.176

1.112

1.064

0.971

0.904

0.840

0.780

0.726

0.697

0.675

0.652

102

1.101

1.038

0.991

0.904

0.840

0.780

0.726

0.697

0.675

0.652

0.629

103

1.029

0.968

0.921

0.840

0.780

0.726

0.697

0.675

0.652

0.629

0.607

104

0.960

0.900

0.854

0.780

0.726

0.697

0.675

0.652

0.629

0.607

0.584

Notes:

Source: Based on the 2009 United States Life Table for the Male Population

Annual Rate of Interest = 3.5%

Annual Rate of Escalation after year 2 = 2.0%

Annuity Values reduced by 2.4% to reflect the expected offset of Massachusetts benefits by Social Security benefits.

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: April 1, 2015

Distributed: January, 2015 Appendix III – Pension Tables

Part VI – Appendices Page 9

Table IIIEF-398 – Female

Pension Table – Permanent Total Claimants

(for Claims after December 23, 1991 Excluding Claims Incurred Under USL&HW Act (with Escalation))

Age at

Accident

Date

ᾱ

(x)

(x) + 1

(x) + 2

(x) + 3

(x) + 4

(x) + 5

(x) + 6

(x) + 7

(x) + 8

(x) + 9

(x)+10

0

42.204

43.200

43.753

41.693

41.326

40.951

40.569

40.181

39.786

39.384

38.976

1

42.463

42.989

43.522

41.463

41.090

40.710

40.324

39.931

39.531

39.126

38.714

2

42.252

42.759

43.279

41.223

40.845

40.460

40.070

39.672

39.268

38.859

38.443

3

42.023

42.517

43.025

40.974

40.591

40.202

39.807

39.405

38.997

38.584

38.166

4

41.782

42.264

42.763

40.717

40.329

39.936

39.536

39.130

38.719

38.303

37.884

5

41.531

42.003

42.490

40.450

40.059

39.661

39.257

38.847

38.433

38.016

37.597

6

41.271

41.732

42.209

40.176

39.779

39.377

38.969

38.557

38.142

37.725

37.306

7

41.001

41.453

41.919

39.892

39.492

39.086

38.675

38.262

37.846

37.429

37.011

8

40.723

41.164

41.620

39.601

39.196

38.787

38.375

37.962

37.547

37.129

36.710

9

40.436

40.867

41.312

39.301

38.893

38.483

38.071

37.657

37.242

36.824

36.402

10

40.141

40.560

40.995

38.994

38.585

38.174

37.762

37.348

36.932

36.512

36.088

11

39.836

40.246

40.671

38.680

38.271

37.861

37.449

37.034

36.615

36.193

35.766

12

39.524

39.924

40.340

38.363

37.954

37.543

37.129

36.712

36.291

35.866

35.436

13

39.204

39.595

40.005

38.041

37.631

37.219

36.803

36.384

35.960

35.532

35.099

14

38.878

39.262

39.666

37.714

37.303

36.889

36.470

36.048

35.621

35.190

34.754

15

38.547

38.925

39.321

37.381

36.968

36.551

36.130

35.704

35.274

34.840

34.401

16

38.212

38.582

38.970

37.042

36.626

36.206

35.781

35.353

34.920

34.482

34.040

17

37.872

38.234

38.612

36.695

36.276

35.853

35.425

34.993

34.557

34.116

33.671

18

37.527

37.879

38.246

36.341

35.919

35.492

35.061

34.626

34.186

33.742

33.293

19

37.174

37.516

37.873

35.979

35.554

35.124

34.689

34.250

33.807

33.359

32.907

20

36.815

37.146

37.492

35.610

35.180

34.747

34.309

33.867

33.420

32.969

32.513

21

36.448

36.768

37.103

35.232

34.799

34.362

33.921

33.475

33.025

32.570

32.111

22

36.073

36.383

36.705

34.847

34.410

33.970

33.525

33.075

32.621

32.163

31.701

23

35.691

35.989

36.300

34.454

34.014

33.569

33.120

32.667

32.210

31.748

31.283

24

35.302

35.587

35.886

34.053

33.609

33.161

32.708

32.251

31.791

31.326

30.857

25

34.904

35.178

35.465

33.644

33.196

32.744

32.288

31.828

31.364

30.895

30.422

26

34.500

34.761

35.036

33.228

32.776

32.320

31.861

31.397

30.929

30.457

29.979

27

34.087

34.337

34.599

32.804

32.348

31.889

31.426

30.959

30.486

30.009

29.527

28

33.668

33.905

34.154

32.373

31.914

31.451

30.984

30.512

30.035

29.553

29.066

29

33.242

33.466

33.701

31.935

31.472

31.006

30.534

30.057

29.576

29.089

28.598

30

32.808

33.020

33.242

31.490

31.024

30.552

30.076

29.595

29.109

28.618

28.123

31

32.368

32.567

32.776

31.038

30.568

30.091

29.610

29.124

28.634

28.140

27.641

32

31.922

32.108

32.304

30.580

30.104

29.623

29.137

28.647

28.153

27.655

27.152

33

31.470

31.642

31.824

30.114

29.633

29.148

28.658

28.164

27.666

27.163

26.657

34

31.012

31.170

31.337

29.641

29.156

28.666

28.172

27.674

27.172

26.666

26.158

35

30.547

30.691

30.843

29.162

28.672

28.179

27.681

27.179

26.673

26.165

25.654

36

30.076

30.205

30.343

28.677

28.184

27.686

27.184

26.678

26.170

25.659

25.145

37

29.599

29.714

29.837

28.187

27.689

27.187

26.682

26.174

25.663

25.149

24.631

38

29.116

29.217

29.326

27.692

27.190

26.684

26.176

25.665

25.152

24.634

24.112

39

28.629

28.715

28.809

27.192

26.686

26.178

25.667

25.154

24.636

24.114

23.589

40

28.136

28.209

28.288

26.688

26.179

25.669

25.155

24.637

24.116

23.590

23.062

41

27.639

27.697

27.763

26.180

25.669

25.156

24.638

24.116

23.591

23.062

22.531

42

27.138

27.182

27.234

25.670

25.156

24.638

24.117

23.592

23.063

22.532

21.998

43

26.633

26.664

26.703

25.156

24.639

24.117

23.592

23.063

22.532

21.998

21.461

44

26.125

26.143

26.168

24.639

24.117

23.592

23.064

22.532

21.998

21.461

20.919

45

25.614

25.619

25.629

24.117

23.592

23.064

22.532

21.998

21.461

20.919

20.372

46

25.101

25.091

25.087

23.592

23.064

22.532

21.998

21.461

20.919

20.372

19.821

47

24.583

24.559

24.540

23.064

22.532

21.998

21.461

20.919

20.372

19.821

19.265

48

24.062

24.023

23.989

22.532

21.998

21.461

20.919

20.372

19.821

19.265

18.706

49

23.536

23.483

23.436

21.998

21.461

20.919

20.372

19.821

19.265

18.706

18.145

50

23.008

22.941

22.881

21.461

20.919

20.372

19.821

19.265

18.706

18.145

17.584

51

22.476

22.397

22.321

20.919

20.372

19.821

19.265

18.706

18.145

17.584

17.023

52

21.943

21.848

21.757

20.372

19.821

19.265

18.706

18.145

17.584

17.023

16.462

53

21.405

21.296

21.188

19.821

19.265

18.706

18.145

17.584

17.023

16.462

15.900

54

20.863

20.738

20.614

19.265

18.706

18.145

17.584

17.023

16.462

15.900

15.338

55

20.317

20.175

20.035

18.706

18.145

17.584

17.023

16.462

15.900

15.338

14.778

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: April 1, 2015

Distributed: January, 2015 Appendix III – Pension Tables

Part VI – Appendices Page 10

Table IIIEF-398 – Female

Pension Table – Permanent Total Claimants

(for Claims after December 23, 1991 Excluding Claims Incurred Under USL&HW Act (with Escalation))

Age at

Accident

Date

ᾱ

(x)

(x) + 1

(x) + 2

(x) + 3

(x) + 4

(x) + 5

(x) + 6

(x) + 7

(x) + 8

(x) + 9

(x)+10

56

19.765

19.608

19.453

18.145

17.584

17.023

16.462

15.900

15.338

14.778

14.219

57

19.209

19.037

18.869

17.584

17.023

16.462

15.900

15.338

14.778

14.219

13.665

58

18.650

18.465

18.285

17.023

16.462

15.900

15.338

14.778

14.219

13.665

13.116

59

18.090

17.893

17.701

16.462

15.900

15.338

14.778

14.219

13.665

13.116

12.569

60

17.529

17.320

17.117

15.900

15.338

14.778

14.219

13.665

13.116

12.569

12.026

61

16.967

16.748

16.532

15.338

14.778

14.219

13.665

13.116

12.569

12.026

11.485

62

16.406

16.174

15.947

14.778

14.219

13.665

13.116

12.569

12.026

11.485

10.951

63

15.844

15.601

15.364

14.219

13.665

13.116

12.569

12.026

11.485

10.951

10.423

64

15.283

15.030

14.782

13.665

13.116

12.569

12.026

11.485

10.951

10.423

9.902

65

14.722

14.460

14.206

13.116

12.569

12.026

11.485

10.951

10.423

9.902

9.391

66

14.164

13.895

13.634

12.569

12.026

11.485

10.951

10.423

9.902

9.391

8.888

67

13.611

13.334

13.065

12.026

11.485

10.951

10.423

9.902

9.391

8.888

8.393

68

13.061

12.777

12.499

11.485

10.951

10.423

9.902

9.391

8.888

8.393

7.908

69

12.515

12.222

11.936

10.951

10.423

9.902

9.391

8.888

8.393

7.908

7.435

70

11.971

11.671

11.380

10.423

9.902

9.391

8.888

8.393

7.908

7.435

6.975

71

11.431

11.126

10.830

9.902

9.391

8.888

8.393

7.908

7.435

6.975

6.526

72

10.897

10.587

10.288

9.391

8.888

8.393

7.908

7.435

6.975

6.526

6.088

73

10.369

10.056

9.756

8.888

8.393

7.908

7.435

6.975

6.526

6.088

5.664

74

9.849

9.535

9.232

8.393

7.908

7.435

6.975

6.526

6.088

5.664

5.258

75

9.338

9.021

8.717

7.908

7.435

6.975

6.526

6.088

5.664

5.258

4.870

76

8.835

8.516

8.212

7.435

6.975

6.526

6.088

5.664

5.258

4.870

4.503

77

8.341

8.021

7.719

6.975

6.526

6.088

5.664

5.258

4.870

4.503

4.160

78

7.856

7.539

7.241

6.526

6.088

5.664

5.258

4.870

4.503

4.160

3.840

79

7.383

7.070

6.774

6.088

5.664

5.258

4.870

4.503

4.160

3.840

3.544

80

6.924

6.613

6.318

5.664

5.258

4.870

4.503

4.160

3.840

3.544

3.268

81

6.476

6.166

5.876

5.258

4.870

4.503

4.160

3.840

3.544

3.268

3.011

82

6.039

5.733

5.454

4.870

4.503

4.160

3.840

3.544

3.268

3.011

2.773

83

5.615

5.320

5.050

4.503

4.160

3.840

3.544

3.268

3.011

2.773

2.553

84

5.211

4.925

4.668

4.160

3.840

3.544

3.268

3.011

2.773

2.553

2.350

85

4.824

4.551

4.311

3.840

3.544

3.268

3.011

2.773

2.553

2.350

2.165

86

4.458

4.201

3.978

3.544

3.268

3.011

2.773

2.553

2.350

2.165

1.996

87

4.116

3.876

3.670

3.268

3.011

2.773

2.553

2.350

2.165

1.996

1.842

88

3.798

3.575

3.382

3.011

2.773

2.553

2.350

2.165

1.996

1.842

1.704

89

3.504

3.293

3.115

2.773

2.553

2.350

2.165

1.996

1.842

1.704

1.583

90

3.229

3.032

2.867

2.553

2.350

2.165

1.996

1.842

1.704

1.583

1.480

91

2.974

2.790

2.638

2.350

2.165

1.996

1.842

1.704

1.583

1.480

1.381

92

2.737

2.566

2.427

2.165

1.996

1.842

1.704

1.583

1.480

1.381

1.287

93

2.519

2.361

2.234

1.996

1.842

1.704

1.583

1.480

1.381

1.287

1.198

94

2.319

2.172

2.057

1.842

1.704

1.583

1.480

1.381

1.287

1.198

1.112

95

2.135

2.001

1.898

1.704

1.583

1.480

1.381

1.287

1.198

1.112

1.030

96

1.968

1.845

1.754

1.583

1.480

1.381

1.287

1.198

1.112

1.030

0.953

97

1.816

1.706

1.627

1.480

1.381

1.287

1.198

1.112

1.030

0.953

0.879

98

1.680

1.583

1.520

1.381

1.287

1.198

1.112

1.030

0.953

0.879

0.810

99

1.560

1.479

1.418

1.287

1.198

1.112

1.030

0.953

0.879

0.810

0.752

100

1.459

1.380

1.320

1.198

1.112

1.030

0.953

0.879

0.810

0.752

0.729

101

1.362

1.285

1.227

1.112

1.030

0.953

0.879

0.810

0.752

0.729

0.705

102

1.270

1.195

1.138

1.030

0.953

0.879

0.810

0.752

0.729

0.705

0.680

103

1.182

1.109

1.053

0.953

0.879

0.810

0.752

0.729

0.705

0.680

0.656

104

1.098

1.027

0.972

0.879

0.810

0.752

0.729

0.705

0.680

0.656

0.630

Notes:

Source: based on the 2009 United States Life Table for the Female Population

Annual Rate of Interest = 3.5%

Annual Rate of Escalation after year 2 = 2.0%

Annuity Values reduced by 2.4% to reflect the expected offset of Massachusetts benefits by Social Security benefits.

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: April 1, 2015

Distributed: January, 2015 Appendix III – Pension Tables

Part VI – Appendices Page 11

Calculation 1st Report 2nd Report 3rd Report

1. Valuation Date

7/2014

7/2015

7/2016

2. Injured worker’s attained age at accident date

36

3. Spouse's attained age at accident date

33

4. Duration since accident date (to nearest year), t.

1

2

3

5. Weekly Benefit Payable

$386.67

$396.34

6. Annual Benefit Payable [ = (5) x 52 ]

$20,107

$20,610

Benefits for Injured Worker beyond the Valuation Date

7. Factor from Table IIIEM-398

28.986

27.612

26.058

8. Factor from Table IE-398

27.526

26.593

25.823

9. Maximum of [ = (7),[2 x (7) + (8)]/3 ], if (8) is n/a then (9) = (7)

28.986

27.612

26.058

10. Present Value of Future Payment [ = (6) x (9) ]

$582,817

$555,183

$537,038

Others

11. Payment since Accident Date

$28,614

$48,720

$127,601

12. Total Incurred Indemnity Loss [ = (10) + (11) ]

$611,430

$603,904

$664,639

Notes:

• (5): The weekly benefit payment is equal to two-thirds of the average weekly wage.

Weekly Benefit Payments are subjected to "Cost of Living Adjustments" (COLA):

Any person receiving or entitled to receive benefits under the provisions of Section 31 or 34A whose benefits are based on a date of

personal injury at least 24 months prior to the review date shall have his weekly benefit adjusted subject to:

o The annual change in the Adjusted Benefit shall not exceed the minimum of:

 The increase in the State Average Weekly Wage (SAWW)

 The increase in the Northeastern region CPI for all urban consumers

 5%

o In no instance shall the adjusted benefit be greater than "three times the base benefit."

Benefit Reevaluation Date

2/5/2013

10/1/2015

COLA Adjustment Factor

1.0250

Adjusted Benefit

$386.67

$396.34

Base Benefit

1

st

Escalated Benefit

Supplemental Benefit

$9.67

Weekly Benefit

$386.67

$396.34*

(Base Benefit + Supplemental Benefit)

Notes:

 *ex. $396.34 = $386.67 x max(1.0250,1.0), to a maximum of $1160 (3 times the $386.67 base benefit)

 If the adjusted benefit is larger than the base benefit, the difference shall be termed the supplemental benefit.

 No increase in benefits shall be payable which would reduce any benefits the recipient is receiving pursuant to federal

social security law.

 For purposes of this example, the COLA Adjustment Factor has been arbitrarily selected. The proper amounts of

adjustments to compensation required under §34B are published by the DIA each October.

 (7), (8): 1st Report factor is from the 9/1/2011 Pension Table, 2nd Report factor is from the 4/1/2015 Pension Table,

3rd Report is from the 4/1/2015 Pension Table.

Example – Permanent Total Claim – Male Worker

Usage of: Permanent Total Claimant’s Pension Table (Table IIIEM-398)

Calculation of incurred loss to be reported when benefits are payable to an injured male worker for life, due to

a permanent total Injury occurring after December 23, 1991.

Accident Date:

2/5/2013

Policy Effective Date:

1/1/2013

Weekly Wages:

$580

Injured Worker’s Birthdate:

2/18/1976

Spouse’s Birthdate:

7/20/1979

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix III – Pension Tables

Part VI – Appendices Page 12

Table UI - USLH

Pension Table - Surviving Spouse

(for Claims Incurred Under USL&HW Act)

Age at

Widowhood

(x)

ᾱ

(x)

ᾱ

(x) + 1

ᾱ

(x) + 2

ᾱ

(x) + 3

ᾱ

(x) + 4

ᾱ

(x) + 5

Attained

Age

(x + 5)

16

26.047

27.027

29.921

31.560

32.873

34.031

21

17

26.221

27.215

30.137

31.796

33.127

34.302

22

18

26.402

27.411

30.362

32.041

33.390

34.584

23

19

26.591

27.615

30.596

32.296

33.664

34.876

24

20

26.787

27.826

30.838

32.561

33.949

35.180

25

21

27.222

28.214

31.192

32.880

34.263

35.496

26

22

27.697

28.611

31.531

33.175

34.553

35.791

27

23

28.196

29.012

31.855

33.437

34.813

36.059

28

24

28.701

29.435

32.202

33.749

35.087

36.296

29

25

29.193

29.847

32.534

34.060

35.350

36.507

30

26

29.659

30.227

32.827

34.337

35.588

36.700

31

27

30.098

30.567

33.074

34.567

35.796

36.883

32

28

30.516

30.875

33.282

34.753

35.978

37.059

33

29

30.929

31.171

33.477

34.919

36.146

37.232

34

30

31.360

31.487

33.692

35.100

36.319

37.400

35

31

31.834

31.861

33.968

35.340

36.517

37.556

36

32

32.372

32.323

34.341

35.674

36.751

37.688

37

33

33.021

32.926

34.814

36.106

37.016

37.779

38

34

33.732

33.615

35.355

36.598

37.281

37.809

39

35

34.440

34.312

35.886

37.063

37.491

37.761

40

36

35.063

34.909

36.301

37.386

37.580

37.621

41

37

35.541

35.329

36.528

37.490

37.508

37.385

42

38

35.819

35.510

36.511

37.316

37.228

37.053

43

39

35.957

35.520

36.323

36.949

36.815

36.630

44

40

35.974

35.404

36.012

36.450

36.311

36.120

45

41

35.902

35.208

35.624

35.881

35.730

35.529

46

42

35.740

34.974

35.204

35.299

35.107

34.865

47

43

35.525

34.737

34.785

34.743

34.474

34.140

48

44

35.274

34.480

34.354

34.193

33.826

33.363

49

45

34.976

34.173

33.887

33.626

33.149

32.545

50

46

34.593

33.779

33.354

33.000

32.424

31.696

51

47

34.098

33.272

32.732

32.293

31.639

30.826

52

48

33.467

32.625

31.997

31.478

30.769

29.943

53

49

32.781

31.915

31.225

30.633

29.889

29.054

54

50

32.048

31.157

30.424

29.771

29.005

28.167

55

51

31.272

30.365

29.604

28.902

28.125

27.287

56

52

30.458

29.549

28.771

28.034

27.250

26.418

57

53

29.615

28.708

27.928

27.171

26.385

25.559

58

54

28.761

27.859

27.080

26.314

25.531

24.711

59

55

27.901

27.007

26.232

25.464

24.685

23.872

60

56

27.043

26.157

25.387

24.621

23.848

23.044

61

57

26.191

25.314

24.550

23.787

23.022

22.227

62

58

25.346

24.478

23.719

22.962

22.205

21.420

63

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix III – Pension Tables

Part VI – Appendices Page 13

Table UI - USLH

Pension Table - Surviving Spouse

(for Claims Incurred Under USL&HW Act)

Age at

Widowhood

(x)

ᾱ

(x)

ᾱ

(x) + 1

ᾱ

(x) + 2

ᾱ

(x) + 3

ᾱ

(x) + 4

ᾱ

(x) + 5

Attained

Age

(x + 5)

59

24.507

23.648

22.897

22.147

21.398

20.625

64

60

23.676

22.827

22.086

21.342

20.602

19.839

65

61

22.856

22.019

21.286

20.548

19.815

19.063

66

62

22.049

21.223

20.498

19.767

19.038

18.295

67

63

21.261

20.443

19.723

18.997

18.272

17.537

68

64

20.488

19.676

18.959

18.237

17.516

16.788

69

65

19.722

18.918

18.203

17.486

16.770

16.049

70

66

18.956

18.161

17.454

16.743

16.033

15.319

71

67

18.204

17.421

16.713

16.009

15.304

14.598

72

68

17.453

16.683

15.981

15.283

14.584

13.887

73

69

16.711

15.957

15.259

14.567

13.876

13.191

74

70

15.980

15.240

14.547

13.861

13.181

12.511

75

71

15.259

14.532

13.846

13.170

12.503

11.847

76

72

14.547

13.833

13.157

12.494

11.841

11.199

77

73

13.844

13.147

12.484

11.834

11.194

10.567

78

74

13.155

12.475

11.826

11.189

10.563

9.954

79

75

12.480

11.817

11.181

10.559

9.950

9.362

80

76

11.821

11.173

10.552

9.947

9.359

8.792

81

77

11.177

10.545

9.941

9.356

8.791

8.247

82

78

10.548

9.935

9.351

8.788

8.246

7.728

83

79

9.937

9.346

8.784

8.243

7.727

7.240

84

80

9.349

8.780

8.240

7.725

7.239

6.784

85

81

8.783

8.238

7.723

7.237

6.783

6.354

86

82

8.241

7.723

7.236

6.782

6.354

5.951

87

83

7.725

7.236

6.782

6.353

5.951

5.573

88

84

7.238

6.782

6.353

5.950

5.573

5.219

89

85

6.782

6.353

5.950

5.573

5.219

4.889

90

86

6.353

5.950

5.572

5.219

4.889

4.580

91

87

5.950

5.572

5.219

4.889

4.580

4.293

92

88

5.572

5.218

4.888

4.580

4.293

4.025

93

89

5.218

4.888

4.580

4.292

4.025

3.775

94

90

4.888

4.580

4.292

4.024

3.774

3.541

95

91

4.580

4.292

4.024

3.774

3.541

3.322

96

92

4.292

4.024

3.774

3.541

3.322

3.116

97

93

4.024

3.774

3.540

3.322

3.116

2.920

98

94

3.774

3.540

3.322

3.116

2.919

2.730

99

95

3.540

3.322

3.116

2.919

2.730

2.542

100

96

3.322

3.116

2.919

2.729

2.542

2.387

101

97

3.116

2.919

2.729

2.541

2.387

2.240

102

98

2.919

2.729

2.541

2.387

2.240

2.093

103

99

2.729

2.541

2.387

2.240

2.093

1.951

104

100

2.541

2.387

2.239

2.093

1.951

1.812

105

101

2.387

2.240

2.093

1.951

1.812

1.662

106

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix III – Pension Tables

Part VI – Appendices Page 14

Table UI - USLH

Pension Table - Surviving Spouse

(for Claims Incurred Under USL&HW Act)

Age at

Widowhood

(x)

ᾱ

(x)

ᾱ

(x) + 1

ᾱ

(x) + 2

ᾱ

(x) + 3

ᾱ

(x) + 4

ᾱ

(x) + 5

Attained

Age

(x + 5)

102

2.240

2.093

1.951

1.812

1.662

1.487

107

103

2.093

1.951

1.812

1.662

1.487

1.275

108

104

1.951

1.812

1.662

1.487

1.275

0.964

109

105

1.812

1.662

1.487

1.275

0.964

0.500

110

106

1.662

1.487

1.275

0.964

0.500

0.000

111

107

1.487

1.275

0.964

0.500

0.000

112

108

1.275

0.964

0.500

0.000

113

109

0.964

0.500

0.000

114

110

0.500

0.000

115

Notes:

1999 United States Life Table for the Female Population

1980 United States of America Railroad Retirement Board Remarriage Table

Annual Rate of Interest = 3.5%

Annual Rate of Escalation = 4.0%

For durations beyond 5 years from death of claimant, use the annuity value in the column for age

(x + 5) corresponding to the beneficiary's attained age.

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix III – Pension Tables

Part VI – Appendices Page 15

Table UII - USLH

Present Value of Remarriage Dowry

(for Claims Incurred Under USL&HW Act)

Age at

Widowhood

(x)

ᾱ

(x)

ᾱ

(x) + 1

ᾱ

(x) + 2

ᾱ

(x) + 3

ᾱ

(x) + 4

ᾱ

(x) + 5

Attained

Age

(x + 5)

16

0.7847

0.7634

0.7240

0.6947

0.6675

0.6408

21

17

0.7729

0.7508

0.7096

0.6790

0.6506

0.6228

22

18

0.7608

0.7377

0.6946

0.6626

0.6330

0.6041

23

19

0.7482

0.7241

0.6790

0.6457

0.6148

0.5847

24

20

0.7351

0.7101

0.6629

0.6281

0.5959

0.5645

25

21

0.7189

0.6935

0.6449

0.6093

0.5761

0.5436

26

22

0.7017

0.6763

0.6265

0.5902

0.5560

0.5224

27

23

0.6836

0.6584

0.6078

0.5710

0.5357

0.5009

28

24

0.6646

0.6396

0.5881

0.5506

0.5146

0.4792

29

25

0.6451

0.6202

0.5680

0.5295

0.4930

0.4574

30

26

0.6252

0.6006

0.5478

0.5083

0.4713

0.4351

31

27

0.6049

0.5809

0.5276

0.4871

0.4493

0.4125

32

28

0.5843

0.5611

0.5075

0.4661

0.4272

0.3894

33

29

0.5630

0.5409

0.4870

0.4448

0.4047

0.3658

34

30

0.5406

0.5196

0.4656

0.4227

0.3816

0.3416

35

31

0.5167

0.4967

0.4426

0.3990

0.3574

0.3171

36

32

0.4907

0.4714

0.4171

0.3729

0.3320

0.2924

37

33

0.4617

0.4427

0.3890

0.3443

0.3053

0.2680

38

34

0.4304

0.4113

0.3586

0.3135

0.2778

0.2442

39

35

0.3979

0.3786

0.3274

0.2823

0.2506

0.2214

40

36

0.3659

0.3466

0.2974

0.2529

0.2252

0.2000

41

37

0.3358

0.3171

0.2704

0.2271

0.2025

0.1803

42

38

0.3089

0.2918

0.2478

0.2067

0.1838

0.1623

43

39

0.2843

0.2695

0.2284

0.1901

0.1678

0.1460

44

40

0.2616

0.2493

0.2114

0.1763

0.1536

0.1316

45

41

0.2402

0.2304

0.1958

0.1640

0.1411

0.1190

46

42

0.2201

0.2118

0.1807

0.1519

0.1296

0.1080

47

43

0.2005

0.1926

0.1650

0.1390

0.1181

0.0985

48

44

0.1810

0.1732

0.1493

0.1257

0.1070

0.0905

49

45

0.1619

0.1544

0.1340

0.1125

0.0964

0.0836

50

46

0.1444

0.1372

0.1200

0.1006

0.0870

0.0777

51

47

0.1294

0.1226

0.1082

0.0908

0.0794

0.0725

52

48

0.1180

0.1117

0.0995

0.0842

0.0743

0.0680

53

49

0.1078

0.1023

0.0918

0.0785

0.0697

0.0638

54

50

0.0989

0.0942

0.0850

0.0734

0.0654

0.0599

55

51

0.0912

0.0872

0.0789

0.0688

0.0613

0.0561

56

52

0.0847

0.0809

0.0733

0.0644

0.0574

0.0523

57

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix III – Pension Tables

Part VI – Appendices Page 16

Table UII - USLH

Present Value of Remarriage Dowry

(for Claims Incurred Under USL&HW Act)

Age at

Widowhood

(x)

ᾱ

(x)

ᾱ

(x) + 1

ᾱ

(x) + 2

ᾱ

(x) + 3

ᾱ

(x) + 4

ᾱ

(x) + 5

Attained

Age

(x + 5)

53

0.0792

0.0756

0.0682

0.0602

0.0535

0.0485

58

54

0.0742

0.0708

0.0635

0.0561

0.0496

0.0448

59

55

0.0697

0.0664

0.0593

0.0522

0.0458

0.0411

60

56

0.0654

0.0622

0.0552

0.0483

0.0420

0.0374

61

57

0.0613

0.0582

0.0513

0.0446

0.0383

0.0338

62

58

0.0574

0.0544

0.0475

0.0409

0.0347

0.0302

63

59

0.0536

0.0506

0.0438

0.0373

0.0312

0.0267

64

60

0.0499

0.0470

0.0402

0.0339

0.0279

0.0234

65

61

0.0462

0.0434

0.0366

0.0305

0.0246

0.0202

66

62

0.0424

0.0398

0.0331

0.0271

0.0215

0.0172

67

63

0.0384

0.0359

0.0294

0.0237

0.0185

0.0145

68

64

0.0341

0.0320

0.0259

0.0205

0.0156

0.0120

69

65

0.0300

0.0282

0.0225

0.0174

0.0131

0.0099

70

66

0.0265

0.0250

0.0194

0.0147

0.0109

0.0081

71

67

0.0229

0.0215

0.0167

0.0125

0.0091

0.0067

72

68

0.0200

0.0187

0.0144

0.0106

0.0077

0.0056

73

69

0.0173

0.0161

0.0123

0.0090

0.0065

0.0047

74

70

0.0149

0.0138

0.0105

0.0076

0.0055

0.0039

75

71

0.0127

0.0117

0.0088

0.0064

0.0045

0.0032

76

72

0.0108

0.0099

0.0074

0.0053

0.0038

0.0027

77

73

0.0092

0.0083

0.0062

0.0044

0.0031

0.0022

78

74

0.0078

0.0071

0.0052

0.0037

0.0026

0.0018

79

75

0.0068

0.0061

0.0044

0.0030

0.0021

0.0014

80

76

0.0058

0.0052

0.0037

0.0025

0.0017

0.0011

81

77

0.0050

0.0045

0.0031

0.0020

0.0013

0.0009

82

78

0.0043

0.0039

0.0026

0.0017

0.0011

0.0008

83

79

0.0037

0.0033

0.0022

0.0014

0.0009

0.0006

84

80

0.0030

0.0027

0.0018

0.0012

0.0008

0.0005

85

81

0.0024

0.0022

0.0015

0.0010

0.0007

0.0004

86

82

0.0018

0.0016

0.0011

0.0008

0.0005

0.0004

87

83

0.0013

0.0012

0.0008

0.0006

0.0004

0.0003

88

84

0.0009

0.0008

0.0006

0.0004

0.0003

89

85

0.0008

0.0007

0.0005

0.0004

0.0003

0.0002

90

86

0.0007

0.0006

0.0005

0.0003

0.0002

91

87

0.0006

0.0004

0.0003

0.0002

92

88

0.0005

0.0004

0.0003

0.0002

0.0001

93

89

0.0005

0.0003

0.0002

0.0001

94

90

0.0004

0.0003

0.0002

0.0001

95

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix III – Pension Tables

Part VI – Appendices Page 17

Table UII - USLH

Present Value of Remarriage Dowry

(for Claims Incurred Under USL&HW Act)

Age at

Widowhood

(x)

ᾱ

(x)

ᾱ

(x) + 1

ᾱ

(x) + 2

ᾱ

(x) + 3

ᾱ

(x) + 4

ᾱ

(x) + 5

Attained

Age

(x + 5)

91

0.0004

0.0003

0.0002

0.0001

96

92

0.0004

0.0003

0.0002

0.0001

97

93

0.0003

0.0002

0.0001

98

94

0.0003

0.0002

0.0001

0.0000

99

95

0.0003

0.0002

0.0001

0.0000

100

96

0.0002

0.0001

0.0000

101

97

0.0002

0.0001

0.0000

102

98

0.0002

0.0001

0.0000

103

99

0.0002

0.0001

0.0000

104

100

0.0002

0.0001

0.0000

105

101

0.0001

0.0002

0.0001

0.0000

106

102

0.0001

0.0002

0.0001

0.0000

107

103

0.0001

0.0002

0.0001

0.0000

108

104

0.0001

0.0000

109

105

0.0001

0.0000

110

Notes:

1999 United States Life Table for the Female Population

1980 United States of America Railroad Retirement Board Remarriage Table

Annual Rate of Interest = 3.5%

Annual Rate of Escalation = 4.0%

For durations beyond 5 years from death of claimant, use the annuity value in the column for age

(x + 5) corresponding to the beneficiary's attained age.

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix III – Pension Tables

Part VI – Appendices Page 18

Calculation 1st Report 2nd Report 3rd Report

1. Valuation Date

7/1998

7/1999

7/2000

2. Spouse's nearest accident date

33

3. Duration since date of death (to nearest year), t.

0

1

2

4. Weekly Benefit Payable [ 50% x Weekly Wages x Escalation ]

$260.00

$270.00

$281.00

5. Annual Benefit Payable [ = (4) x 52 ]

$13,520

$14,040

$14,612

6. Factor from Table UI-USLH

33.021

32.926

34.814

7. Present Value of Future Payment [ = (5) x (6) ]

$446,444

$462,281

$508,702

Others

8. Two Year Remarriage Payment [ = (5) x (2) ]

$27,040

$28,080

$29,224

9. Factor from Table UII-USLH

0.4617

0.4427

0.3890

10. Present Value of Future Remarriage Payment [ = (8) x (9) ]

$12,484

$12,431

$11,368

11. Payment since Date of Death

$10,510

$24,290

$38,632

12. Funeral Allowance

$2,000

13. Total Incurred Indemnity Loss [ = (7) + (10) + (11) + (12) ]

$471,438

$501,002

$560,702

Note:

• Escalation Rate = 0.04

Example - Fatal Claim – USL&H

Usage of: Surviving Spouse's Pension Table (Table UI-USLH) & Remarriage Dowry (Table UII-USLH)

Calculation of incurred loss to be reported when benefits are payable to a surviving spouse until death or

remarriage, due to a fatal injury occurring after December 23, 1991.

Accident Date

9/16/1997

Policy Effective Date:

1/1/1997

Date of Death:

9/16/1997

Spouse's Birthdate:

2/18/1965

Weekly Wages:

$500

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix III – Pension Tables

Part VI – Appendices Page 19

Table UIIIM - USLH

Male – Pension Table Other than Surviving Spouse

(for Claims Incurred Under USL&HW Act)

11

75.314

40

40.351

69

14.047

98

2.568

12

73.964

41

39.262

70

13.387

99

2.419

13

72.624

42

38.184

71

12.747

100

2.268

14

71.301

43

37.115

72

12.123

15

69.995

44

36.059

73

11.516

16

68.708

45

35.013

74

10.926

17

67.438

46

33.981

75

10.353

18

66.183

47

32.961

76

9.796

19

64.940

48

31.954

77

9.253

20

63.706

49

30.957

78

8.724

21

62.482

50

29.971

79

8.211

22

61.268

51

28.995

80

7.718

23

60.061

52

28.030

81

7.249

24

58.860

53

27.076

82

6.806

25

57.661

54

26.136

83

6.392

26

56.465

55

25.211

84

6.003

27

55.273

56

24.303

85

5.635

28

54.083

57

23.412

86

5.290

29

52.900

58

22.538

87

4.968

30

51.722

59

21.681

88

4.666

31

50.551

60

20.840

89

4.385

32

49.387

61

20.014

90

4.122

33

48.229

62

19.205

91

3.878

34

47.080

63

18.414

92

3.651

35

45.937

64

17.641

93

3.439

36

44.803

65

16.887

94

3.242

37

43.677

66

16.150

95

3.058

38

42.559

67

15.430

96

2.885

39

41.450

68

14.728

97

2.723

Notes:

1999 United States Life Table for the Male Population

Annual Rate of Interest = 3.5%

Annual Rate of Escalation = 4.0%

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix III – Pension Tables

Part VI – Appendices Page 20

Table UIIIF - USLH

Female – Pension Table Other than Surviving Spouse

(for Claims Incurred Under USL&HW Act)

Age

ᾱ

Age

ᾱ

Age

ᾱ

Age

ᾱ

11

82.580

40

45.719

69

16.950

98

2.916

12

81.196

41

44.566

70

16.176

99

2.725

13

79.819

42

43.423

71

15.418

100

2.535

14

78.453

43

42.289

72

14.675

15

77.098

44

41.164

73

13.948

16

75.755

45

40.048

74

13.239

17

74.422

46

38.942

75

12.549

18

73.099

47

37.845

76

11.877

19

71.783

48

36.760

77

11.222

20

70.474

49

35.684

78

10.585

21

69.170

50

34.619

79

9.967

22

67.871

51

33.564

80

9.372

23

66.580

52

32.521

81

8.800

24

65.294

53

31.490

82

8.252

25

64.015

54

30.470

83

7.733

26

62.742

55

29.464

84

7.243

27

61.476

56

28.472

85

6.786

28

60.217

57

27.495

86

6.356

29

58.965

58

26.533

87

5.952

30

57.720

59

25.585

88

5.574

31

56.482

60

24.651

89

5.220

32

55.251

61

23.732

90

4.889

33

54.029

62

22.829

91

4.580

34

52.815

63

21.942

92

4.292

35

51.611

64

21.071

93

4.024

36

50.415

65

20.216

94

3.774

37

49.228

66

19.376

95

3.539

38

48.049

67

18.551

96

3.320

39

46.880

68

17.742

97

3.113

Notes:

1999 United States Life Table for the Female Population

Annual Rate of Interest = 3.5%

Annual Rate of Escalation = 4.0%

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix III – Pension Tables

Part VI – Appendices Page 21

Table UIV - USLH

Present Value of Survivorship Benefits

(for Claims Incurred Under USL&HW Act)

Age Difference (Spouse's Age minus Claimant's Age)

Claimant’s

Age

-5 -4 -3 -2 -1 -0

16

10.877

17

11.497

10.819

18

12.138

11.436

10.761

19

12.798

12.073

11.374

10.701

20

13.477

12.730

12.008

11.312

10.641

21

14.172

13.406

12.663

11.943

11.249

10.581

22

14.098

13.336

12.595

11.878

11.186

10.519

23

14.025

13.265

12.527

11.812

11.122

10.457

24

13.952

13.195

12.458

11.745

11.057

10.395

25

13.879

13.124

12.390

11.679

10.993

10.332

26

13.806

13.053

12.321

11.612

10.928

10.269

27

13.733

12.983

12.253

11.546

10.864

10.207

28

13.660

12.912

12.184

11.479

10.799

10.144

29

13.587

12.840

12.115

11.412

10.734

10.081

30

13.512

12.768

12.045

11.344

10.669

10.018

31

13.438

12.696

11.974

11.276

10.602

9.953

32

13.362

12.622

11.903

11.207

10.535

9.888

33

13.285

12.548

11.831

11.136

10.466

9.821

34

13.208

12.472

11.757

11.064

10.396

9.752

35

13.128

12.395

11.682

10.991

10.324

9.682

36

13.048

12.316

11.604

10.915

10.250

9.609

37

12.965

12.235

11.525

10.837

10.174

9.534

38

12.881

12.152

11.444

10.757

10.095

9.457

39

12.794

12.066

11.359

10.674

10.014

9.378

40

12.704

11.978

11.272

10.589

9.930

9.296

41

12.611

11.886

11.181

10.500

9.843

9.211

42

12.514

11.791

11.088

10.408

9.753

9.123

43

12.414

11.692

10.991

10.313

9.660

9.032

44

12.310

11.590

10.891

10.215

9.564

8.938

45

12.202

11.484

10.787

10.113

9.465

8.841

46

12.090

11.374

10.679

10.007

9.361

8.740

47

11.974

11.259

10.566

9.897

9.253

8.634

48

11.852

11.140

10.449

9.782

9.141

8.525

49

11.727

11.017

10.329

9.664

9.026

8.414

50

11.598

10.890

10.204

9.543

8.908

8.300

51

11.465

10.759

10.077

9.419

8.788

8.184

52

11.327

10.625

9.946

9.292

8.665

8.065

53

11.186

10.487

9.812

9.163

8.540

7.944

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix III – Pension Tables

Part VI – Appendices Page 22

Table UIV - USLH

Present Value of Survivorship Benefits

(for Claims Incurred Under USL&HW Act)

Age Difference (Spouse's Age minus Claimant's Age)

54

11.039

10.345

9.674

9.029

8.411

7.820

55

10.888

10.198

9.532

8.891

8.278

7.693

56

10.730

10.045

9.383

8.748

8.141

7.561

57

10.565

9.886

9.230

8.600

7.999

7.425

58

10.395

9.720

9.070

8.447

7.852

7.284

59

10.219

9.551

8.907

8.291

7.702

7.140

60

10.039

9.378

8.741

8.131

7.548

6.992

61

9.856

9.201

8.571

7.967

7.391

6.841

62

9.668

9.020

8.397

7.800

7.230

6.687

63

9.475

8.834

8.218

7.628

7.065

6.529

64

9.277

8.643

8.034

7.451

6.896

6.367

65

9.074

8.448

7.847

7.271

6.723

6.200

66

8.868

8.250

7.656

7.088

6.546

6.031

67

8.659

8.048

7.462

6.901

6.367

5.859

68

8.445

7.842

7.263

6.710

6.183

5.683

69

8.226

7.631

7.060

6.514

5.996

5.504

70

8.001

7.414

6.851

6.314

5.804

5.321

71

7.771

7.193

6.638

6.110

5.609

5.135

72

7.538

6.969

6.424

5.905

5.413

5.013

73

7.303

6.743

6.207

5.698

5.291

4.906

74

7.064

6.514

5.988

5.577

5.186

4.724

75

6.822

6.282

5.868

5.473

4.994

4.542

76

6.577

6.164

5.768

5.271

4.802

4.361

77

6.464

6.071

5.558

5.072

4.614

4.183

78

6.381

5.851

5.349

4.875

4.427

4.007

79

6.150

5.633

5.142

4.679

4.242

3.834

80

5.919

5.414

4.934

4.482

4.059

3.664

81

5.686

5.192

4.725

4.286

3.876

3.496

82

5.448

4.967

4.514

4.090

3.695

3.330

83

5.206

4.740

4.302

3.894

3.515

3.167

84

4.962

4.511

4.090

3.699

3.338

3.007

85

4.716

4.283

3.879

3.506

3.164

2.853

86

4.472

4.057

3.673

3.320

2.998

2.704

87

4.232

3.838

3.474

3.142

2.838

2.560

88

3.999

3.626

3.285

2.971

2.684

2.423

89

3.775

3.425

3.102

2.807

2.537

2.291

90

3.562

3.232

2.928

2.650

2.396

2.165

91

3.358

3.047

2.761

2.500

2.262

2.045

92

3.163

2.871

2.603

2.358

2.135

1.931

93

2.978

2.703

2.452

2.223

2.014

1.824

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix III – Pension Tables

Part VI – Appendices Page 23

Table UIV - USLH

Present Value of Survivorship Benefits

(for Claims Incurred Under USL&HW Act)

Age Difference (Spouse's Age minus Claimant's Age)

94

2.802

2.545

2.310

2.095

1.899

1.721

95

2.635

2.395

2.175

1.974

1.791

1.623

96

2.479

2.254

2.048

1.860

1.688

1.530

97

2.332

2.122

1.929

1.752

1.590

1.440

98

2.196

1.999

1.818

1.652

1.498

1.354

99

2.071

1.886

1.716

1.558

1.411

1.273

100

1.960

1.786

1.624

1.473

1.331

1.197

101

1.842

1.677

1.523

1.378

1.241

1.127

102

1.730

1.573

1.425

1.285

1.168

1.058

103

1.624

1.473

1.329

1.210

1.097

0.988

104

1.520

1.373

1.252

1.136

1.025

0.918

105

1.420

1.295

1.178

1.063

0.953

0.845

Notes:

1999 United States Life Table for the Total Population and the Female Population

Remarriage rates based on the 1980 United States of America Railroad Retirement Board Remarriage Table

Annual Rate of Interest = 3.5%

Annual Rate of Escalation = 4.0%

MASSACHUSETTS WORKERS’ COMPENSATION

STATISTICAL PLAN

Effective: August 14, 2013

Distributed: August, 2013 Appendix III – Pension Tables

Part VI – Appendices Page 24

Calculation 1st Report 2nd Report 3rd Report

1. Valuation Date

7/1998

7/1999

7/2000

2. Injured worker’s age nearest valuation date

35

36

38

3. Difference in ages (Spouse – Employee)

-2

4. Weekly Benefit Payable [ 66.67% x Weekly Wage x Escalation ]

$208.00

$216.00

$225.00

5. Annual Benefit Payable [ = (4) x 52 ]

$10,816

$11,232

$11,700

6. Factor from Table UIIIM-USLH

45.937

44.803 43.677

7. Present Value of Future Payments [ = (5) x (6) ]

$496,855

$503,227

$511,021

Others

8. Initial annual survivorship benefit [ = 50% x Weekly Wage x 52) ]

$27,040

$28,080

$29,224

9. Factor from Table UIV-USLH

10.991

10.915

10.837

10. Present Value of Future Remarriage Payment [ = (8) x (9) ]

$85,730

$85,137

$84,529

11. Payment since Accident Date

$11,408

$22,432

$33,916

12. Total Incurred Indemnity Loss [ = (7) + (10) + (11) ]

$593,992

$610,796

$629,466

Note:

• Escalation Rate = 0.04

Example - USL&H

Usage of: Other than Surviving Spouse Pension Table (Table UIIIM-USLH) &

Survivorship Benefits (Table UIV-USLH)

Calculation of incurred loss to be reported when benefits are escalated annually payable for life to an injured

employee due to a permanent total disability and when, upon death of the employee, benefits are payable to

the surviving spouse.

Accident Date

5/30/1997

Policy Effective Date:

1/1/1997

Weekly Wages:

$300

Injured Worker’s Birthdate:

10/21/1963

Spouse's Birthdate:

7/16/1965