Statistical Plan / PART II

Report the code that corresponds to the policy valuation month. This code indicates whether the report is a 1^st or subsequent report.

Report the sequential code that corresponds to the number of correction reports submitted within a particular report level. Report “0” for original report level submissions. Report “1” through “9” and then “A” through “Z” as a correction number within a particular report level. Contact the Rating Board  if additional numbers are required.

Example: First correction to a first report = Report Number “1”, Correction Sequence Number “1”.

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

Note: This field must be left blank for original report level submissions.

Report an “R” to identify reports being submitted to replace an entire report that was previously submitted and failed (rejected). Refer to Part V, Item 5 of this Plan for detailed instructions for submitting replacement reports.

Report the 5-digit numeric code assigned to the reporting carrier by the Rating Board or NCCI. This numeric code must remain the same throughout the life of the policy, unless a correction has been submitted revising the carrier code previously reported.

Report the policy number (up to 18 positions) that uniquely identifies the policy under which the experience occurred, excluding blanks, punctuation marks, and special characters. This number must be identical to the number set forth on the Policy Information Page or as endorsed. The complete policy number including prefixes or suffixes, if used, must remain the same throughout the life of the policy and the reporting of experience under that policy, unless a correction report has been submitted to revise the policy number.

Report, in the format (YYMMDD), the year, month and day upon which the policy became effective.

Report the effective date that corresponds exactly to the date shown on the Policy Information Page or to endorsements attached. In cases where an interstate policy was endorsed after the policy effective date to provide coverage for an additional state, report the effective date of the policy.

For the second and third annual periods of three-year variable rate policies, report the effective date as one and two years, respectively, subsequent to the policy effective date on the Policy Information Page. For the first period, report the policy effective date as shown on the Policy Information Page, or as endorsed. In the event the policy contains WC 00 04 05 “Policy Period Endorsement”, then the effective date must coincide with the dates indicated on the schedule of that endorsement. Refer to Part (I), Item (19)  of this Plan for additional information.

For the second annual period of extended-term policies, report the effective date as the second period began as shown in the WC 00 04 05 “Policy Period Endorsement”.

Report, in the format (YYMMDD), the year, month and day on which the policy expired.

If the policy was canceled, report the cancelation date as the expiration date. For policies that are canceled flat (e.g. policy effective date = policy expiration date), unit statistical reports are not required.

A policy issued no longer than one year and 16 days is treated as a one-year policy and the expiration date shown on the Policy Information Page is reported.

For the first and second annual periods of three-year variable rate policies, report the expiration date as one and two years, respectively, subsequent to the policy effective date set forth on the Policy Information Page. For the third period, report the policy expiration date as shown on the Policy Information Page, or as endorsed. In the event the policy contains WC 00 04 05 "Policy Period Endorsement", then the expiration date must coincide with the date indicated in the schedule of that endorsement.

For the first and second periods of extended-term policies, report the associated expiration date for each term shown in the WC 00 04 05 “Policy Period Endorsement”.

Report the state in which coverage is provided. The exposure state should always be “31” for New York. If New York is not the exposure state a USR is not required to be submitted to the Rating Board.

Report in the format (YYMMDD), the year, month and day of the endorsement effective date if the New York Coverage was endorsed mid-term; otherwise, zero-fill this field.

Report the 7-position Coverage Identification Number assigned by the Rating Board, if available.

Report the primary name of the employer as shown in Item 1. of the Policy Information Page or as endorsed.

Report the street address, city, state and zip code of the employer as shown on Item 1. of the Policy Information Page or as endorsed.

Report the Federal Employer Identification Number of the employer shown on the Policy Information Page.

Report the 1 position alphabetical code for each of the policy conditions that apply to the statistical data being reported:

Report the codes that correspond to the Type of Coverage, Plan Indicator and Non-Standard provisions of the policy.

1. Type of Coverage

   Code	Description
   01	Standard Workers’ Compensation Policy – Coverage determined by the carrier approved rate and classification code to which exposure has been assigned under the provisions of the standard Workers’ Compensation and Employers’ Liability policy.
   09	Non-Standard Policy – The standard workers’ compensation policy has been endorsed to either provide additional coverage or to limit coverage (policies endorsed by WC 31 03 03 A “New York Excess Medical Coverage Endorsement”, excess medical, or WC 31 03 10 “New York Medical Benefits Reimbursement Endorsement”, excluding medical).

2. Type of Plan

   Code	Description
   01	Voluntary Policy – The policy was written voluntarily by the carrier.

3. Type of Non-Standard Provisions

   Code	Description
   01	Non-Standard Does Not Apply – Coverages as described under the standard Workers’ Compensation and Employers’ Liability policy without non-standard exclusions, endorsements or exceptions.
   02	Excluding Medical – employer pays all medical costs; applies to all policies endorsed by WC 31 03 10 “New York Medical Benefits Reimbursement Endorsement” that are not also endorsed by WC 31 03 03 A “New York Excess Medical Coverage Endorsement”.
   06	Excess Medical – Carrier reimburses employer for medical costs that exceed a specified per claim or per accident insured retention; applicable to policies endorsed by WC 31 03 03 A “New York Excess Medical Coverage Endorsement”.

Report the code that identifies the Type of Deductible and Type of Plan being reported.

1. Type of Deductible (first two positions)

   Code	Description
   00	No Deductible – No Deductible Applies
   01	Medical Losses Only – The deductible applies only to the medical portion of the loss.
   02	Indemnity Losses Only – The deductible applies only to the indemnity portion of the loss.
   03	Medical and Indemnity Losses Combined – The deductible applies to the total loss (medical plus indemnity portions).

2. Type of Plan (last two positions)

   Code	Description
   00	No Deductible – There is no applicable deductible program for this policy/state.
   01	Per Claim – The deductible amount applies to each claim arising for the policy.
   02	Per Accident – The deductible amount applies to each accident arising for the policy. If multiple claims arise from one accident, apply the deductible amount only once (to one claim). If the use of one claim is less than the deductible reimbursement, use more than one claim and proportionately distribute the deductible amount as a method.
   03	Per Policy (Aggregate) – The employer is responsible for losses up to the aggregate limit.
   04	Percent of Claim Cost – The employer is responsible for a pre-defined percentage of claim costs arising from the policy.
   05	Percent of Premium – The employer is responsible for losses up to a percentage of premium as determined by the carrier.
   06	Coinsurance Only – The employer is responsible for a certain percent of the claim and the carrier is responsible for the remaining percent of the claim. (Percentages may vary.)
   07	Benefit Coinsurance – The deductible amount applies to each claim. For the remainder of the claim, the employer is responsible for a percentage and the carrier is responsible for the remaining percent. (Percentages may vary.)
   08	Per Accident Coinsurance – The deductible amount applies to each accident.  For the remainder of the claim, the employer is responsible for a certain percentage and the carrier is responsible for the remaining percent. (Percentages may vary.)
   09	Per Policy and Accident (Aggregate) – The deductible amount applies to each accident up to an aggregate limit.
   10	Per Claim and Policy (Aggregate) – The deductible amount applies to each claim up to an aggregate limit.
   11	Coinsurance Percent With Per Claim and Policy Aggregate Limit – The employer is responsible for a percent of the claim, both a per claim and a policy aggregated deductible amount applicable to each claim and policy.
   12	Variable – Carrier Program not described above.

Report the whole percent of the deductible to be paid by the employer, if applicable, as defined by the deductible program. Applicable only with deductible types 0104, 0105, 0111, 0204, 0205, 0211, 0304, 0305, and 0311. (Example: 15% must be reported as 15).

Report the loss amount for each claim/accident to be paid by the employer, if applicable, as defined by the deductible program.

Report the maximum loss amount for all claims to be paid by the employer, if applicable, as defined by the deductible program.