Reporting Number and Valuation Date
Code Description 1 Valued as of the 18th month after the month in which the policy became effective 2 Valued 30 months after the month in which the policy became effective 3 Valued 42 months after the month in which the policy became effective 4 Valued 54 months after the month in which the policy became effective 5 Valued 66 months after the month in which the policy became effective 6 Valued 78 months after the month in which the policy became effective 7 Valued 90 months after the month in which the policy became effective 8 Valued 102 months after the month in which the policy became effective 9 Valued 104 months after the month in which the policy became effective A Valued 126 months after the month in which the policy became effective Correction Type
Indicates the type of correction report being submitted. Applicable only to correction reports.
Code Description H Header Record Correction E Exposure Record Correction (First Reports Only) L Loss Record Correction T Total Record Correction Only M Multiple Record Corrections Exposure State
The following state code number must be used: New York – 31.
Policy Conditions
Report the 1-position code for each policy condition.
Three Year Fixed Rate Indicator
“Y” = Policy is a three-year fixed rate policy
“N” = Policy is not a three-year fixed rate policyMulti-state Policy Indicator
“Y” = Policy is a multi-state policy
“N” = Policy is not a multi-state policyInterstate Policy Indicator
“Y” = Policy is interstate rated
“N” = Policy is not interstate ratedEstimated Audit Code
“Y” = Exposures expressed on unit report are estimated
“N” = Exposures expressed on unit report are not estimated
“U” = Exposures expressed on unit report are estimated – uncooperative insuredRetrospective Rated Policy Indicator
“Y” = Policy is retrospectively rated
“N” = Policy is not retrospectively ratedCanceled Mid-Term Indicator
“Y” = Policy has been canceled mid-term
“N” = Policy has not been canceled mid-termManaged Care Organization Indicator
“Y” = Policy has provisions for the administration of losses under an approved managed care organization or preferred provider organization
“N” = Policy does not have provisions for the administration of losses by an approved managed care organization or preferred provider organization
Policy Type ID
Identifies the type of coverage, plan indicator and non-standard provisions of the policy.
Type of Coverage
Code Description 01 Standard Workers’ Compensation Policy 09 Non-Standard Policy Plan Type
Code Description 01 Voluntary Policy Non-Standard Type
Code Description 01 Non-Standard Code Does Not Apply 02 Excluding Medical 06 Excess Medical
Deductible Type
Identifies the type of deductible being reported.
Type of Deductible – First Two Positions
Code Description 00 No Deductible 01 Medical Losses Only 02 Indemnity Losses Only 03 Medical & Indemnity Losses Type of Plan – Second Two Positions
Code Description 00 No Deductible 01 Per Claim 02 Per Accident 03 Per Policy (Aggregate) 04 Percent of Claim Cost 05 Percent of Premium 06 Coinsurance Only 07 Benefit Coinsurance 08 Per Accident Coinsurance 09 Per Policy and Accident (Aggregate) 10 Per Claim and Policy (Aggregate) 11 Coinsurance Percent With Claim and Policy Aggregate Limits 12 Variable
-
Update Type
Identifies the activity of an exposure record.
Code Description P Previously Reported R Revised -
Exposure Coverage
Indicates the Act (Law) under which the exposure for the record’s classification code is associated.
Code Description 00 For use with Statistical Codes 01 State or Federal Act, Excluding USL & HW 02 USL & HW Coverage on “F” or non “F” Classifications -
Premium Codes
-
Premium Subject to Experience Modification (Reported Above Line “A”)
-
Premium for Increased Limits
Description Code Employers’ Liability Increased Limits (in 000’s) With Workers’ Compensation $100/100/1,000 9803 $100/100/2,500 9804 $100/100/5,000 9805 $100/100/10,000 9806 $500/500/500 9807 $500/500/1,000 9808 $500/500/2,500 9809 $500/500/5,000 9810 $500/500/10,000 9811 $1,000/1,000/1,000 9812 $1,000/1,000/2,500 9813 $1,000/1,000/5,000 9814 $1,000/1,000/,10,000 9815 Over $1,000/1,000/10,000 9816 Description Code Employers’ Liability Increased Limits (in 000’s) Without Workers’ Compensation $100/100/1,000 9823 $100/100/2,500 9824 $100/100/5,000 9825 $100/100/10,000 9826 $500/500/500 9827 $500/500/1,000 9828 $500/500/2,500 9829 $500/500/5,000 9830 $500/500/10,000 9831 $1,000/1,000/1,000 9832 $1,000/1,000/2,500 9833 $1,000/1,000/5,000 9834 $1,000/1,000/,10,000 9835 Over $1,000/1,000/10,000 9836 All Other Increased Limits 9837 For unpublished limits within the table, use the next highest limit code. Employers’ Liability Increased Limits – Admiralty or FELA Code $50,000 9817 $100,000 9818 $200,000 9819 $300,000 9820 $400,000 9821 $500,000 9822 Over $500,000 9840 Employers’ Liability Increased Limits – Additional Premium to Balance to Minimum 9848 Note: The increased limits premium applicable to non-ratable classification exposures should be reported as not subject to the experience modification.
-
Construction Employment Territory Differential Premium
Description Code Territory 1 9126 Territory 2 9127 Territory 3 9128
Description Code - Premium Credit From Carrier Filed Drug-Free Workplace Program Before Experience Modification
9841 - Additional Premium From Flat Increase on Outstanding Policies
0998 - Premium Credit Resulting From Flat Decrease on Outstanding Policies
0994 - Deductible Applied to Manual Premium Before Experience Modification
9664 - No Exposure (“If Any”)
1111 - EL Extension under VFBL
9850 - EL Extension under VAWBL
9851 - Repatriation Expense
9606 - Waiver of Subrogation Premium
0930 -
-
Premium Not Subject to Experience Modification (Lines “D”, “E” or “F”)
Description Code - Radiation Exposure
9985 - CPAP Premium Credit
9046 - Premium Credit From Carrier Filed Drug-Free Workplace Program After Experience Rating
9846 - Deductible Applied to Manual Premium From Carrier Filed Deductible Programs After Experience Modification
9663 - Premium Credit From Managed Care or Preferred Provider Organization Programs
9874 - New York Merit Rating Program (Not applicable for policies with effective dates on or after October 1, 2022)
Factor = .92
Factor = 1.00
Factor = 1.04
Factor = 1.08
9885
9884
9896
9886- Premium to Balance To Minimum Premium
Other Than Maritime or FELA
Maritime or FELA
9884
9849- Non-Ratable Elements
For Class 4771
For Class 7405
For Class 7431
0771
7445
7453- Compulsory Workplace Safety Program Surcharge
9747 -
Premium Not Subject to Experience Modification (Lines “D”, “E” or “F”)
Description Code - Radiation Exposure
9985 - CPAP Premium Credit
9046 - Premium Credit From Carrier Filed Drug-Free Workplace Program After Experience Rating
9846 - Deductible Applied to Manual Premium From Carrier Filed Deductible Programs After Experience Modification
9663 - Premium Credit From Managed Care or Preferred Provider Organization Programs
9874 - New York Merit Rating Program
Factor = .92
Factor = 1.00
Factor = 1.04
Factor = 1.08
9885
9884
9896
9886- Premium to Balance To Minimum Premium
Other Than Maritime or FELA
Maritime or FELA
9884
9849- Non-Ratable Elements
For Class 4771
For Class 7405
For Class 7431
0771
7445
7453- Compulsory Workplace Safety Program Surcharge
9747 - Workplace Safety & Loss Prevention Program (WSLPIP) Credits
Drug & Alcohol Prevention
Return-To-Work
Safety Incentive
9753
9743
9748- Short Rate Penalty Premium
0931 - Safe Patient Handling Program Premium Credit
9651 - Schedule Rating Adjustment
Credit
Debit
9887
9889 -
Premium Not Subject to Experience Modification and Not to be Included in Standard Premium (Lines “H”, “I” or “J”).
Description Code - Premium Discount Amount-Stock Company or Type A
0063 - Premium Discount Amount-Non-Stock Company or Type B
0064 - Expense Constant Amount
0900 - Terrorism Premium Amount
9740 - Natural Disaster & Catastrophic Industrial Accidents Premium
9741 - New York WC Security Fund Surcharge
9749
-
-
Update Type
Identifies the activity of an exposure record.
Code Description P Previously Reported R Revised -
Exposure Coverage
Indicates the Act (Law) under which the exposure for the record’s classification code is associated.
Code Description 00 For use with Statistical Codes 01 State or Federal Act, Excluding USL & HW 02 USL & HW Coverage on “F” or non “F” Classifications -
Premium Codes
-
Premium Subject to Experience Modification (Reported Above Line “A”)
-
Premium for Increased Limits
Description Code Employers’ Liability Increased Limits (in 000’s) With Workers’ Compensation $100/100/1,000 9803 $100/100/2,500 9804 $100/100/5,000 9805 $100/100/10,000 9806 $500/500/500 9807 $500/500/1,000 9808 $500/500/2,500 9809 $500/500/5,000 9810 $500/500/10,000 9811 $1,000/1,000/1,000 9812 $1,000/1,000/2,500 9813 $1,000/1,000/5,000 9814 $1,000/1,000/,10,000 9815 Over $1,000/1,000/10,000 9816 Description Code Employers’ Liability Increased Limits (in 000’s) Without Workers’ Compensation $100/100/1,000 9823 $100/100/2,500 9824 $100/100/5,000 9825 $100/100/10,000 9826 $500/500/500 9827 $500/500/1,000 9828 $500/500/2,500 9829 $500/500/5,000 9830 $500/500/10,000 9831 $1,000/1,000/1,000 9832 $1,000/1,000/2,500 9833 $1,000/1,000/5,000 9834 $1,000/1,000/,10,000 9835 Over $1,000/1,000/10,000 9836 All Other Increased Limits 9837 For unpublished limits within the table, use the next highest limit code. Employers’ Liability Increased Limits – Admiralty or FELA Code $50,000 9817 $100,000 9818 $200,000 9819 $300,000 9820 $400,000 9821 $500,000 9822 Over $500,000 9840 Employers’ Liability Increased Limits – Additional Premium to Balance to Minimum 9848 Note: The increased limits premium applicable to non-ratable classification exposures should be reported as not subject to the experience modification.
-
Construction Employment Territory Differential Premium
Description Code Territory 1 9126 Territory 2 9127 Territory 3 9128
Description Code - Premium Credit From Carrier Filed Drug-Free Workplace Program Before Experience Modification
9841 - Additional Premium From Flat Increase on Outstanding Policies
0998 - Premium Credit Resulting From Flat Decrease on Outstanding Policies
0994 - Deductible Applied to Manual Premium Before Experience Modification
9664 - No Exposure (“If Any”)
1111 - EL Extension under VFBL
9850 - EL Extension under VAWBL
9851 - Repatriation Expense
9606 - Waiver of Subrogation Premium
0930 -
-
Premium Not Subject to Experience Modification (Lines “D”, “E” or “F”)
Description Code - Radiation Exposure
9985 - CPAP Premium Credit
9046 - Premium Credit From Carrier Filed Drug-Free Workplace Program After Experience Rating
9846 - Deductible Applied to Manual Premium From Carrier Filed Deductible Programs After Experience Modification
9663 - Premium Credit From Managed Care or Preferred Provider Organization Programs
9874 - New York Merit Rating Program
Factor = .92
Factor = 1.00
Factor = 1.04
Factor = 1.08
9885
9884
9896
9886- Premium to Balance To Minimum Premium
Other Than Maritime or FELA
Maritime or FELA
0990
9849- Non-Ratable Elements
For Class 4771
For Class 7405
For Class 7431
0771
7445
7453- Compulsory Workplace Safety Program Surcharge
9747 - Workplace Safety & Loss Prevention Program (WSLPIP) Credits
Drug & Alcohol Prevention
Return-To-Work
Safety Incentive
9753
9743
9748- Short Rate Penalty Premium
0931 - Safe Patient Handling Program Premium Credit
9651 - Schedule Rating Adjustment
Credit
Debit
9887
9889 -
Premium Not Subject to Experience Modification and Not to be Included in Standard Premium (Lines “H”, “I” or “J”).
Description Code - Premium Discount Amount-Stock Company or Type A
0063 - Premium Discount Amount-Non-Stock Company or Type B
0064 - Expense Constant Amount
0900 - Terrorism Premium Amount
9740 - Natural Disaster & Catastrophic Industrial Accidents Premium
9741 - New York WC Security Fund Surcharge
9749
-
Injury Type
Code Description 1 Death 2 Permanent Total Disability 5 Temporary Total Disability 6 Medical Only Claims 7 Contract Medical 10 Permanent Partial Disability – Scheduled – Loss – Of – Use 11 Permanent Partial Disability – Non-Scheduled Claim Status
Code Description 0 Open 1 Closed 2 Reopened Loss Conditions
Act
Code Description 01 State or Federal Act, excluding USL & HW 02 USL & HW “F” Classes or USL & HW Coverage on Non “F” Classifications Type of Loss
Code Description 01 Trauma 02 Occupational Disease (OD) 03 Cumulative Injury Other Than Disease Type of Recovery
Code Description 01 No Recovery 03 Subrogation (Third Party) Type of Claim
Code Description 01 Workers’ Compensation Only 02 Employers’ Liability Only 03 Workers’ Compensation & Employers’ Liability 04 Liability-Over Type of Settlement
Code Description 00 Claim Not Subject to Settlement 03 Section 32 Settlement 05 Dismissal (Non-Compensable) 09 All Other Settlements
Managed Care Organization Type
Code Description 00 The claim is not administrated by an approved managed care or preferred provider organization 01 The claim’s medical losses are administrated by an approved managed care organization 03 The claim’s medical losses are administrated by a licensed preferred provider organization Fraudulent Claim Codes
Code Description 00 Not Fraudulent 01 Partially Fraudulent 02 Fully Fraudulent Injury Description Codes
- Part – identify the part of body injured
- Nature – identify the nature of the injury
- Cause – identify the specific cause of injury
Refer to the following Injury Description Codes:
| INJURY DESCRIPTION CODES – PART OF BODY | ||
| CODE | PART OF BODY | NARRATIVE DESCRIPTION |
| I. Head | ||
| 10 | Multiple Head Injury | Any combination of below parts |
| 11 | Skull | * |
| 12 | Brain | * |
| 13 | Ear(s) | Includes: hearing, inside eardrum |
| 14 | Eye(s) | Includes: optic nerves, vision, eye lids |
| 15 | Nose | Includes: nasal passage, sinus, sense of smell |
| 16 | Teeth | * |
| 17 | Mouth | Includes: lips, tongue, throat, taste |
| 18 | Soft Tissue | * |
| 19 | Facial Bones | Includes: jaw |
| II. Neck | ||
| 20 | Multiple Neck Injury | Any combination of below parts |
| 21 | Vertebrae | Includes: spinal column bone, “cervical segment” |
| 22 | Disc | Includes: spinal column cartilage, “cervical segment” |
| 23 | Spinal Cord | Includes: nerve tissue, “cervical segment” |
| 24 | Larynx | Includes: cartilage and vocal cords |
| 25 | Soft Tissue | Other than larynx or trachea |
| 26 | Trachea | * |
| III. Upper Extremities | ||
| 30 | Multiple Upper Extremities | Any combination of below parts, excluding hands and wrists combined |
| 31 | Upper Arm | Humerus and corresponding muscles, excluding clavicle and scapula |
| 32 | Elbow | Radial head |
| 33 | Lower Arm | Fore Arm – radius, ulna and corresponding muscles |
| 34 | Wrist | Carpals and corresponding muscles |
| 35 | Hand | Metacarpals and corresponding muscles – excluding wrist or fingers |
| 36 | Finger(s) | Other than thumb and corresponding muscles |
| 37 | Thumb | * |
| 38 | Shoulder(s) | Armpit, rotator cuff, trapezius, clavicle, scapula |
| 39 | Wrist(s) and Hand(s) | * |
| IV. Trunk | ||
| 40 | Multiple Trunk | Any combination of below parts |
| 41 | Upper Back Area | (Thoracic Area) Upper back muscles, excluding, vertebrae, disc, spinal cord |
| 42 | Lower Back Area | (Lumbar Area and Lumbo Sacral) Lower back muscles, excluding sacrum, coccyx, pelvis, vertebrae, disc, spinal cord |
| 43 | Disc | Spinal column cartilage other than cervical segment |
| 44 | Chest | Including ribs, sternum, soft tissue |
| 45 | Sacrum and Coccyx | Final nine vertebrae-fused |
| 46 | Pelvis | * |
| 47 | Spinal Cord | Nerve tissue other than cervical segment |
| 48 | Internal Organs | Other than heart and lungs |
| 49 | Heart | * |
| 60 | Lungs | * |
| 61 | Abdomen Including Groin | Excluding injury to internal organs |
| 62 | Buttock Soft Tissue | Soft tissue |
| 63 | Lumbar & or Sacral Vertebrae (Vertebrae NOC trunk) |
Bone portion of the spinal column |
| V. Lower Extremities | ||
| 50 | Multiple Lower Extremities | Any combination of below parts |
| 51 | Hip | * |
| 52 | Upper Leg | Femur and corresponding muscles |
| 53 | Knee | Patella |
| 54 | Lower Leg | Tibia, fibula and corresponding muscles |
| 55 | Ankle | Tarsals |
| 56 | Foot | Metatarsals, heel, Achilles tendon and corresponding muscles – excluding ankle or toes |
| 57 | Toes | * |
| 58 | Great Toe | * |
| VI. Multiple Body Parts | ||
| 64 | Artificial Appliance | Braces, etc. |
| 65 | Insufficient Info to Properly Identify – Unclassified | Insufficient information to identify part affected |
| 66 | No physical Injury | Mental disorder |
| 90 | Multiple Body Parts (including Body Systems & Body Parts) | Applies when more than one major body part has been affected, such as an arm and a leg and multiple internal organs. |
| 91 | Body Systems and Multiple Body Systems | Applies to the functioning of an entire body system has been affected without specific injury to any other part, as in the case of poisoning, corrosive action, inflammation, affecting internal organs, damage to nerve centers, etc., does not apply when the systemic damage results from an external injury affecting an external part such as a back injury which includes damage to the nerves of the spinal cord. |
| INJURY DESCRIPTION CODES – NATURE OF INJURY | ||
| CODE | NATURE OF INJURY | NARRATIVE DESCRIPTION |
| I. Specific Injury | ||
| 01 | No Physical Injury | i.e., Glasses, contact lenses, artificial appliance, replacement of artificial appliance |
| 02 | Amputation | Cut off extremity, digit, protruding part of body, usually by surgery, i.e. leg, arm |
| 03 | Angina Pectoris | Chest pain |
| 04 | Burn | (Heat) Burns or scald. The effect of contact with hot substances. |
| 07 | Concussion | Brain, cerebral |
| 10 | Contusion | Bruise - intact skin surface hematoma |
| 13 | Crushing | To grind, pound or break into small bits |
| 16 | Dislocation | Pinched nerve, slipped/ruptured disc, herniated disc, sciatica, complete tear, HNP subluxtion, MD dislocation |
| 19 | Electric Shock | Electrocution |
| 22 | Enucleation | Removal of organ or tumor |
| 25 | Foreign Body | * |
| 28 | Fracture | Breaking of a bone or cartilage |
| 30 | Freezing | Frostbite and other effects of exposure to low temperature |
| 31 | Hearing Loss or Impairment | Traumatic only. A separate injury, not the sequelae of another injury. |
| 32 | Heat Prostration | Heat stroke, sun stroke, heat exhaustion, heat cramps and other effects of environmental heat. Does not include sunburn. |
| 34 | Hernia | The abnormal protrusion of an organ or part through the containing wall of its cavity. |
| 36 | Infection | The invasion of a host by organisms such as bacteria, fungi, viruses, mold, protozoa or insects, with or without manifest disease. |
| 37 | Inflammation | The reaction of tissue to injury characterized clinically by heat, swelling, redness and pain. |
| 40 | Laceration | Cut, scratches, abrasions, superficial wounds, calluses, wound by tearing |
| 41 | Myocardial Infarction | Heart attack, heart conditions, hypertension. The inadequate blood flow to the muscular tissue of the heart. |
| 42 | Poisoning – General (Not OD or Cumulative Injury) | A systemic morbid condition resulting from the inhalation, ingestion, or skin absorption of a toxic substance affecting the metabolic system, the nervous system, the circulatory system, the digestive system, the respiratory system, the excretory system, the musculoskeletal system, etc. includes chemical or drug poisoning, metal poisoning, organic diseases, and venomous reptile and insect bites. Does NOT include effects of radiation, pneumoconiosis, corrosive effects of chemicals; skin surface irritations, septicemia or infected wounds. |
| 43 | Puncture | A hole made by the piercing of a pointed instrument. |
| 46 | Rupture | * |
| 47 | Severance | To separate, divide or take off. |
| 49 | Sprain | Internal derangement, a trauma or wrenching of a joint, producing pain and disability depending upon degree of injury to ligaments. |
| 52 | Strain | Internal derangement, the trauma to the muscle or the musculotendinous unit from violent contraction or excessive forcible stretch. |
| 54 | Asphyxiation | Strangulation, drowning |
| 55 | Vascular | Cerebrovascular and other conditions of circulatory systems, NOC, excludes heart and hemorrhoids. Includes: strokes, varicose veins - non toxic. |
| 58 | Vision Loss | * |
| 59 | All Other Specific Injuries, NOC | * |
| II. Occupational Disease or Cumulative Injury | ||
| 60 | Dust Disease, NOC | All other pneumoconiosis |
| 61 | Asbestosis | Lung disease, a form of pneumoconiosis, resulting from protracted inhalation of asbestos particles. |
| 62 | Black Lung | The chronic lung disease or pneumoconiosis found in coal miners. |
| 63 | Byssinosis | Pneumoconiosis of cotton, flax and hemp workers |
| 64 | Silicosis | Pneumoconiosis resulting from inhalation of silica (quartz) dust. |
| 65 | Respiratory Disorders | Gases, fumes, chemicals, etc. |
| 66 | Poisoning – Chemical (Other Than Metals) | Man-made or organic |
| 67 | Poisoning – Metal | Man-made |
| 68 | Dermatitis | Rash, skin or tissue inflammation including boils, etc., generally resulting from direct contact with irritants or sensitizing chemicals such as drugs, oils, biologic agents, plants, woods or metals which may be in the form of solids, pastes, liquids or vapors and which may be contacted in the pure state or in compounds or in combination with other materials. Does NOT include skin tissue damage resulting from corrosive action of chemicals, burns from contact with hot substances, effects of exposure to radiation, effects of exposure to low temperatures or inflammation or irritation resulting from friction or impact. |
| 69 | Mental Disorder | A clinically significant behavioral or psychological syndrome or pattern typically associated with either a distressing symptom or impairment of function. i.e., acute anxiety, neurosis, stress, non-toxic depression. |
| 70 | Radiation | All forms of damage to tissue, bones or body fluids produced by exposure to radiation. |
| 71 | All Other Occupational Disease Injury, NOC | * |
| 72 | Loss of Hearing | * |
| 73 | Contagious Disease | * |
| 74 | Cancer | * |
| 75 | AIDS | * |
| 76 | VDT – Related Diseases | Video display terminal diseases other than carpal tunnel syndrome |
| 77 | Mental Stress | * |
| 78 | Carpal Tunnel Syndrome | Soreness, tenderness and weakness of the muscles of the thumb caused by pressure on the median nerve at the point at which it goes through the carpal tunnel of the wrist |
| 79 | Hepatitis C | * |
| 80 | All Other Cumulative Injury, NOC | * |
| 83 | COVID-19 | Coronavirus disease 2019 (COVID-19) is a respiratory disease caused by a coronavirus. |
| III. Multiple Injury | ||
| 90 | Multiple Physical Injuries Only | * |
| 91 | Multiple Injuries Including Both Physical and Physiological | * |
| INJURY DESCRIPTION CODES – CAUSE OF INJURY | ||
| CODE | CAUSE OF INJURY | NARRATIVE DESCRIPTION |
| I. Burn or Scald – Heat or Cold Exposures – Contact With | ||
| 01 | Chemicals | Includes hydrochloric acid, sulfuric acid, battery acid, methanol, antifreeze. |
| 02 | Hot Objects or Substances | * |
| 03 | Temperature Extremes | Non-impact injuries resulting in a burn due to hot or cold temperature extremes. Includes freezing or frostbite. |
| 04 | Fire or Flame | * |
| 05 | Steam or Hot Fluids | * |
| 06 | Dust, Gases, Fumes or Vapors | Includes inhalation of carbon dioxide, carbon monoxide, propane, methane, silica (quartz), asbestos dust and smoke. |
| 07 | Welding Operations | Includes welder's flash (burns to skin or eyes as a result of exposure to intense light from welding.) |
| 08 | Radiation | Includes effects of ionizing radiation found in X- rays, microwaves, nuclear reactor waste, and radiating substances and equipment. Includes non-ionizing radiation such as sunburn. |
| 11 | Cold Objects or Substances | * |
| 14 | Abnormal Air Pressure | * |
| 84 | Electrical Current | Includes electric shock, electrocution and lightning. |
| 09 | Contact With, NOC | Not otherwise classified in any other code. Includes cleaning agents and fertilizers. |
| II. Caught In, Under or Between | ||
| 10 | Machine or Machinery | Running or meshing objects, a moving and a stationary object, two or more moving objects |
| 12 | Object Handled | Includes medical hospital bed & parts, wheelchair, clothespin vise. |
| 20 | Collapsing Materials (Slides of Earth) | Either man-made or natural. |
| 13 | Caught In, Under or Between, NOC | Not otherwise classified in any other code. |
| III. Cut, Puncture, Scrape – Injured By | ||
| 15 | Broken Glass | * |
| 16 | Hand Tool, Utensil; Not Powered | Includes needle, pencil, knife, hammer, saw, axe, screwdriver. |
| 17 | Object Being Lifted or Handled | Includes being cut, punctured or scraped by a person or object being lifted or handled. |
| 18 | Powered Hand Tool, Appliance | Includes drill, grinder, sander, iron, blender, welding tools, nail gun. |
| 19 | Caught, Puncture, Scrape, NOC | Not otherwise classified in any other code. Includes power actuated tools. |
| IV. Fall, Slip or Trip | ||
| 25 | From Different Level (Elevation) | Includes collapsing chairs, falling from piled materials, off wall, catwalk, bridge. |
| 26 | From Ladder or Scaffolding | * |
| 27 | From Liquid or Grease Spills | * |
| 28 | Into Openings | Includes mining shafts, excavations, floor openings, elevator shafts. |
| 29 | On Same Level | * |
| 30 | Slipped, Did Not Fall | Slip or trip and did not come in contact with the floor or ground. |
| 32 | On Ice or Snow | * |
| 33 | On Stairs | * |
| 31 | Fall, Slip or Trip, NOC | Not otherwise classified in any other code. Includes tripping over object, slipping on organic material, slip but fall not specified. |
| V. Motor Vehicle | ||
| 40 | Crash of Water Vehicle | * |
| 41 | Crash of Rail Vehicle | * |
| 45 | Collision or Sideswipe with Another Vehicle | Vehicle collision, both vehicles in motion. |
| 46 | Collision with a Fixed Object | Collision occurring with standing vehicle or stationary object. |
| 47 | Crash of Airplane | * |
| 48 | Vehicle Upset | Includes overturned or jackknifed. |
| 50 | Motor Vehicle, NOC | Not otherwise classified in any other code. Includes injuries due to sudden stop or start, being thrown against interior parts of the vehicle and vehicle contents being thrown against occupants. |
| VI. Strain or Injury By | ||
| 52 | Continual Noise | Injury to ears or hearing due to the cumulative effects of constant or repetitive noise. |
| 53 | Twisting | Free bodily motion that imposes stress or strain on some part of body. Includes assumption of unnatural position, involuntary motions induced by sudden noise, fright or loss of balance. |
| 54 | Jumping | * |
| 55 | Holding or Carrying | Applies to objects or people. Includes restraining a person. |
| 56 | Lifting | Includes objects or people. |
| 57 | Pushing or Pulling | Includes objects or people. |
| 58 | Reaching | * |
| 59 | Using Tool or Machinery | * |
| 61 | Wielding or Throwing | Physical effort or overexertion from attempts to resist a force applied by an object being handled. |
| 97 | Repetitive Motion | Cumulative injury or condition caused by continual, repeated motions; strain by excessive use. Includes Carpal Tunnel Syndrome. |
| 60 | Strain or Injury By, NOC | Not otherwise classified in any other code. |
| VII. Striking Against or Stepping On | ||
| 65 | Moving Part of Machine | * |
| 66 | Object Being Lifted or Handled | * |
| 67 | Sanding, Scraping, Cleaning Operation | Include scratches or abrasions caused by sanding, scraping, cleaning operations. |
| 68 | Stationary Object | * |
| 69 | Stepping on Sharp Object | * |
| 70 | Striking Against or Stepping On, NOC | Not otherwise classified in any other code. |
| 74 | Fellow Worker; Patient | Struck by co-worker, either on purpose or accidentally. Includes being struck by a patient while lifting or moving them not in act of a crime. |
| 75 | Falling or Flying Object | * |
| 76 | Hand Tool or Machine in Use | * |
| 77 | Motor Vehicle | Applies when a person is struck by a motor vehicle, including rail vehicles, water vehicles, airplanes. |
| 78 | Moving Parts of Machine | * |
| 79 | Objects Being Lifted or Handled | Includes dropping object on body part. |
| 80 | Object Handled By Others | Includes another person dropping object on injured person's body part. |
| 85 | Animal or Insect | Includes bite, sting or allergic reaction. |
| 86 | Explosion or Flare Back | Rapid expansion, outbreak, bursting, or upheaval. Includes explosion of cars, bottles, aerosol cans, or buildings. "Flare back" involves superheated air and combustible gases at temperatures just below the ignition temperature. |
| 81 | Struck or Injured, NOC | Not otherwise classified in any other code. Includes kicked, stabbed, bitten. |
| IX. Rubbed or Abraded By | ||
| 94 | Repetitive Motion | Caused by repeated rubbing or abrading; applies to non-impact cases in which the injury was produced by pressure, vibration or friction between the person and the source of injury. Includes callous, blister. |
| 95 | Rubbed or Abraded, NOC | Not otherwise classified in any other code. Includes foreign body in ears. |
| X. Miscellaneous Causes | ||
| 82 | Absorption, Ingestion or Inhalation, NOC | Not otherwise classified in any other code. Applies only to non-impact cases in which the injury resulted from inhalation, absorption (skin contact), or ingestion of harmful substances. |
| 83 | Pandemic | Includes disease epidemic that has spread across a large region. |
| 87 | Foreign Matter (Body) in (Eyes) | Injury to eyes resulting from foreign matter that is not otherwise classified in any other code. |
| 88 | Natural Disaster | Injury resulting from natural disaster. Includes hurricane, earthquake, tornado, flood, forest fire. |
| 89 | Person in Act of a Crime (Other Than Gunshot) | Specific injury, other than gunshot, caused as a result of contact between injured person and another person in the act of committing a crime. Includes robbery or criminal assault. |
| 90 | Other Than Physical Cause of Injury | Stress, shock, or psychological trauma that develops in relation to a specific incident or cumulative exposure to conditions. |
| 93 | Gunshot | Injury is caused by the discharge of a firearm. Includes instances where injury arises from being struck by the fired projectile, burned by muzzle blast or deafened by report of gunshot. |
| 91 | Mold | Includes mildew. |
| 96 | Terrorism | An act that causes injury to human life, committed by one or more individuals as part of an effort to coerce a population group(s) or to influence the policy or affect the conduct of any government(s) by coercion. |
| 98 | Cumulative, NOC | Cumulative, not otherwise classified in any other code. Involves cases in which the cause of injury occurred over a period of time, any condition increasing in severity over time. |
| 99 | Other – Miscellaneous, NOC | Not otherwise classified in any other code. |
Jurisdiction State Code identifies the governing jurisdiction that administers the claim.
| STATE | CODE | STATE | CODE | STATE | CODE |
| Alabama | 01 | Louisiana | 17 | Oklahoma | 35 |
| Alaska | 54 | Maine | 18 | Oregon | 36 |
| Arizona | 02 | Maryland | 19 | Pennsylvania | 37 |
| Arkansas | 03 | Massachusetts | 20 | Puerto Rico | 58 |
| California | 04 | Michigan | 21 | Rhode Island | 38 |
| Colorado | 05 | Minnesota | 22 | South Carolina | 39 |
| Connecticut | 06 | Mississippi | 23 | South Dakota | 40 |
| Delaware | 07 | Missouri | 24 | Tennessee | 41 |
| District of Columbia | 08 | Montana | 25 | Texas | 42 |
| Florida | 09 | Nebraska | 26 | Utah | 43 |
| Georgia | 10 | Nevada | 27 | Vermont | 44 |
| Hawaii | 52 | New Hampshire | 28 | Virginia | 45 |
| Idaho | 11 | New Jersey | 29 | Washington | 46 |
| Illinois | 12 | New Mexico | 30 | West Virginia | 47 |
| Indiana | 13 | New York | 31 | Wisconsin | 48 |
| Iowa | 14 | North Carolina | 32 | Wyoming | 49 |
| Kansas | 15 | North Dakota | 33 | ||
| Kentucky | 16 | Ohio | 34 |