Utah Workers Compensation Insurer Loss Costs Multiplier Filing Form printable pdf download

UTAH

WORKERS COMPENSATION

INSURER LOSS COSTS MULTIPLIER FILING FORMS

PAGE 1

Date: ____________________

INSURER NAME

___________________________________________________________________________________

ADDRESS

___________________________________________________________________________________

PERSON RESPONSIBLE FOR FILING __________________________________________________________________

TITLE ___________________________________________________ TELEPHONE # ____________________________

INSURER NAIC#

_______________

NAIC GROUP # ______________

DESIGNATED RATE SERV. ORG. REFERENCE FILING#__________________________________________________

The insurer hereby files to be deemed to have independently submitted as its own filing the prospective loss costs in

the captioned Reference Filing.

The insurer’s rates will be the combination of the prospective loss costs and the loss cost multipliers and, if utilized,

the expense constants specified in the attachments.

PROPOSED RATE LEVEL CHANGE ____________%

EFFECTIVE DATE _____________

PRIOR RATE LEVEL CHANGE

____________%

EFFECTIVE DATE _____________

ATTACH PAGE 2 WHICH SHOWS THE CALCULATION OF THE LOSS COSTS MULTIPLIER.

The insurer hereby files to have its loss cost multiplier be applicable to future revisions of the designated rate service

organization’s prospective loss costs for this line of insurance. The insurer’s rate will be the combination of the

designated rate service organization’s prospective loss costs and the insurer’s loss costs multiplier(s) specified in the

attachment. The rates will apply to policies written on or after the effective date of the designated rate service

organization’s prospective loss costs. This authorization is effective until disapproved by the Commissioner, or

amended or withdrawn by the insurer.

ut-wclcm -10/03

Utah Workers Compensation Insurer Loss Costs Multiplier Filing Form