Circular Letter No. 6 (2008): Reference Filing Adoption Form (Revised)
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2REFERENCE FILING ADOPTION FORM (REVISED)
LOSS COST FILING DOCUMENT - WORKERS COMPENSATION
CALCULATION OF COMPANY LOSS COST MULTIPLIER WITH EXPENSE CONSTANT
EFFECTIVE APRIL 1, 2008
INSURER NAME
__________________________________________________________
ADDRESS
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
PERSON RESPONSIBLE FOR FILING
_______________________________
TITLE _________________________ TELEPHONE #
____________________________
INSURER NAIC #
________________________________________
If this is a loss cost filing adopting an advisory organization's loss costs, the above insurer hereby
declares that it is a member, subscriber or service purchaser of the named advisory organization for this
line of insurance. The insurer hereby files (to be deemed to have independently submitted as its own
filing) the prospective loss costs of the advisory organization.
The insurer hereby files to have its loss cost multipliers, expense constants and minimum premiums to be
applicable to future revisions of the advisory organization's prospective loss costs for this line of insurance.
The insurer's rates will be the combination of the advisory organization's prospective loss costs and the
insurer's loss cost multipliers, expense constants and minimum premiums specified in the attachments. The
rates will apply to policies written on or after the effective date of the advisory organization's prospective loss
costs. The authorization is effective until disapproved by the Superintendent, or until amended or withdrawn
by the insurer.
1. Loss Cost modification:
The insurer hereby files to adopt the prospective loss costs in the captioned reference filing:
(Check one)
A. ( ) Without modification (factor = 1.000)
B. ( ) With a modification of ___________ (Cite the percent modification, and
attach supporting data including a minimum of the latest five years of loss
and premium data for both the company and the group as a whole, if
applicable, on an accident year basis. This data should include any policies
written on a large deductible basis.)
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