A. Codes Common To Premium And Losses

1. Report 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 policy effective date
  3 Valued 42 months after the policy effective date
  4 Valued 54 months after the policy effective date
  5 Valued 66 months after the policy effective date
  6 Valued 78 months after the policy effective date
  7 Valued 90 months after the policy effective date
  8 Valued 102 months after the policy effective date
  9 Valued 114 months after the policy effective date
  A Valued 126 months after the policy effective date
     
2. 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
     
3. Exposure State
     
  The following state code number must be used: New York-31

4. Policy Conditions
     
  Report the 1-position code for each policy condition.
     
  a. Three Year Fixed Rate Indicator
“Y” = Policy is a three-year fixed rate policy
“N” = Policy is not a three-year fixed rate policy
     
  b. Multi-state Policy Indicator
“Y” = Policy is a multi-state policy
“N” = Policy is not a multi-state policy
     
  c. Interstate Policy Indicator
“Y” = Policy is interstate rated
“N” = Policy is not interstate rated
     
  d. Estimated 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 insured
     
  e. Retrospective Rated Policy Indicator
“Y” = Policy is retrospectively rated
“N” = Policy is not retrospectively rated
     
  f. Cancelled Mid-Term Indicator
“Y” = Policy has been cancelled mid-term
“N” = Policy has not been cancelled mid-term
     
  g. Managed 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
 

5. Policy Type ID
       
  Identifies the type of coverage, plan indicator and non-standard provisions of the policy.
     
  a. Type of Coverage
    Code Description
    01 Standard Workers Compensation Policy
    09 Non-Standard Policy
       
  b. Plan Type
    Code Description
    01 Voluntary Policy
       
  c. Non-Standard Type
    Code Description
    01 Non-Standard Code Does Not Apply
    02 Excluding Medical
    06 Excess Medical
       
6. Deductible Type
       
  Identifies the type of deductible being reported.
       
  a. Type of Deductible - First Two Positions
    Code Description
    00 No Deductible
    01 Medical Losses Only
    02 Indemnity Losses Only
    03 Medical & Indemnity Losses
 
       
  b. 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 & Accident (Aggregate)
    10 Per Claim and Policy Aggregate
    11 Coinsurance Percent With Claim and Policy Aggregate Limits
    12 Variable

 

1. Update Type
     
  Identifies the activity of an exposure record.
     
  Code Description
  P Previously Reported
  R Revised
     
2. Exposure Coverage
     
  Indicates the Act (Law) under which the exposure for the record’s class 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” Classes
     

3. Premium Codes
       
  a. Premium Subject to Experience Modification (Reported Above Line “A”)
       
    (1) 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
           
      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.  
           
    (2) Construction Employment Territory Differential Premium
      Description Code
      Territory 1 9126
      Territory 2 9127
      Territory 3 9128
         
    (3) Premium Credit From Carrier Filed Drug-Free Workplace Program  
        Before Experience Modification 9841
         
    (4) Additional Premium From Flat Increase on Outstanding Policies 0998
         
    (5) Premium Credit Resulting From Flat Decrease on Outstanding Policies 0994
         
    (6) Deductible Applied to Manual Premium Before Experience Modification 9664
         
    (7) No Exposure (“If Any”) 1111
         
    (8) EL extension Under VFBL 9850
         
    (9) EL extension under VAWBL 9851
         
    (10) Repatriation Expense 9606
         
    (11) Waiver of Subrogation Premium 0930

  b. Premium Not Subject to Experience Modification (Lines "D", "E" or "F")
       
    Description Code
    (1) Radiation Exposure 9985
         
    (2) CPAP Premium Credit 9046
         
    (3) Premium Credit From Carrier Filed Drug-Free Workplace Program  
        After Experience Rating 9846
         
    (4) Deductible Applied to Manual Premium From Carrier Filed  
        Deductible Programs After Experience Modification 9663
         
    (5) Premium Credit From Managed Care or Preferred Provider  
        Organization Programs 9874
           
    (6) New York Merit Rating Program  
        Factor = .92 9885
        Factor = 1.00 9884
        Factor = 1.04 9896
        Factor = 1.08 9886
           
    (7) Premium To Balance To Minimum Premium  
        Other Than Maritime or FELA 0990
        Maritime or FELA 9849
           
    (8) Non-Ratable Elements  
        For Class 4771 0771
        For Class 7405 7445
        For Class 7431 7453
           
    (9) Compulsory Workplace Safety Program Surcharge 9747
           
    (10) Workplace Safety & Loss Prevention Program (WSLPIP) Credits  
        Drug & Alcohol Prevention 9753
        Return-To-Work 9743
        Safety Incentive 9748
           
    (11) Short Rate Penalty Premium 0931
         
    (12) Safe Patient Handling Program Premium Credit 9651
         
    (13) Schedule Rating Adjustment  
      Credit 9887
      Debit 9889
         
  c. Premium Not Subject to Experience Modification and Not to be Included in Standard Premium (Lines "H", "I", or "J").
         
    (1) Premium Discount Amount-Stock Company or Type A 0063
    (2) Premium Discount Amount-Non-Stock Company or Type B 0064
    (3) Expense Constant Amount 0900
    (4) Terrorism Premium Amount 9740
    (5) Natural Disaster & Catastrophic Industrial Accidents Premium 9741
    (6) New York WC Security Fund Surcharge 9749
  1. Injury Type
    CodeDescription
    01Death
    02Permanent Total Disability
    05Temporary Total Disability
    06Medical Only Claims
    07Contract Medical
    10Permanent Partial Disability – Scheduled-Loss-Of-Use
    11Permanent Partial Disability – Non-Scheduled


  2. Claim Status
    CodeDescription
    0Open
    1Closed
    2Reopened


  3. Loss Conditions
    1. Act
      CodeDescription
      01State or Federal Act, excluding USL&HW
      02USL&HW “F” Classes or USL&HW Coverage on Non-“F” Classes


    2. Type of Loss
      CodeDescription
      01Trauma
      02Occupational Disease (OD)
      03Cumulative Injury Other Than Disease


    3. Type of Recovery
      CodeDescription
      01No Recovery
      02Special Disability Fund (Second Injury) Only
      03Subrogation Only (Third Party)
      04Subrogation with Special Disability Fund (Second Injury)


    4. Type of Claim
      CodeDescription
      01Workers Compensation Only
      02Employers Liability Only
      03Workers Compensation & Employers Liability
      04Liability-Over


    5. Type of Settlement
      CodeDescription
      00Claim Not Subject to Settlement
      03Section 32 Settlement
      05Dismissal (Non-Compensable)
      09 All Other Settlements


  4. Managed Care Organization Type
    CodeDescription
    00The claim is not administrated by an approved managed care or preferred provider organization
    01The 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


  5. Fraudulent Claim Codes
    CodeDescription
    00Not Fraudulent
    01Partially Fraudulent
    02 Fully Fraudulent


  6. Injury Description Codes
    1. Part - identify the part of body injured
    2. Nature - identify the nature of the injury
    3. Cause - identify the specific cause of injury
    4. Refer to the following Injury Description Codes:
Injury Description Codes – Part of Body
 CodePart of BodyNarrative Description
I.Head  
 10Multiple Head InjuryAny combination of parts below.
 11Skull 
 12Brain 
 13Ear(s)Includes: hearing, inside eardrum
 14Eye(s)Includes: optic nerves, vision, eye lids
 15NoseIncludes: nasal passage, sinus, sense of smell
 16Teeth 
 17MouthIncludes: lips, tongue, throat, taste
 18Soft Tissue 
 19Facial BonesIncludes: jaw
II.Neck  
 20Multiple Neck InjuryAny combination of parts below.
 21VertebraeIncludes: spinal column bone, "cervical segment"
 22DiscIncludes: spinal column cartilage, "cervical segment"
 23Spinal CordIncludes: nerve tissue, "cervical segment"
 24LarynxIncludes: cartilage and vocal cords
 25Soft TissueOther than larynx or trachea.
 26Trachea 
III.Upper
Extremities
  
 30Multiple Upper ExtremitiesAny combination of parts below, excluding hands and wrists combined.
 31Upper ArmHumerus and corresponding muscles, excluding clavicle and scapula.
 32ElbowRadial head
 33Lower ArmForearm - radius, ulna and corresponding muscles.
 34WristCarpals and corresponding muscles.
 35HandMetacarpals and corresponding muscles excluding wrist or fingers.
 36Finger(s)Other than thumb and corresponding muscles.
 37Thumb 
 38Shoulder(s)Armpit, rotator cuff, trapezius, clavicle, scapula.
 39Wrist(s) and Hand(s) 
IV.Trunk  
 40Multiple TrunkAny combination of parts below.
 41Upper Back Area(Thoracic area) upper back muscles, excluding vertebrae, disc, spinal cord.
 42Lower Back Area(Lumbar area and lumbo sacral) lower back muscles, excluding sacrum, coccyx, pelvis, vertebrae, disc, spinal cord.
 43DiscSpinal column cartilage other than cervical segment.
 44ChestIncluding ribs, sternum, soft tissue.
 45Sacrum and CoccyxFinal nine vertebrae - fused.
 46Pelvis 
 47Spinal CordNerve tissue other than cervical segment.
 48Internal OrgansOther than heart and lungs.
 49Heart 
 60Lungs 
 61Abdomen Including GroinExcluding injury to internal organs.
 62Buttocks Soft Tissue 
 63Lumbar & or Sacral Vertebrae
(Vertebra NOC trunk)
Bone portion of the spinal column
V.Lower
Extremities
  
 50Multiple Lower ExtremitiesAny combination of parts below.
 51Hips 
 52Upper LegFemur and corresponding muscles.
 53KneePatella
 54Lower LegTibia, fibula and corresponding muscles.
 55AnkleTarsals
 56FootMetatarsals, heel, achilles tendon and corresponding muscles - excluding ankle or toes.
 57Toes 
 58Great Toe 
VI.Multiple Body
Parts
  
 64Artificial ApplianceBraces, etc.
 65Insufficient Info to Properly Identify -UnclassifiedInsufficient information to identity part affected.
 66No Physical InjuryMental disorder
 90Multiple 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.
 91Body Systems and Multiple Body SystemsApplies 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
 CodeNature of InjuryNarrative Description
I.Specific Injury  
 01No Physical Injuryi.e., glasses, contact lenses, artificial appliance, replacement of artificial appliance.
 02AmputationCut off extremity, digit, protruding part of body, usually by surgery, i.e., leg, arm.
 03Angina PectorisChest pain
 04Burn(Heat burns or scald). The effect of contact with hot substances.
(Chemical burns). Tissue damage resulting from the corrosive action.
Chemicals, fumes, etc. (acids, alkalies)
 07ConcussionBrain, cerebral
 10ContusionBruise - intact skin surface. Hematoma
 13CrushingGround, pounded or broken into small bits.
 16DislocationPinched nerve, slipped/ruptured disc, herniated disc, sciatica, complete tear, HNP subluxation, MD dislocation.
 19Electric ShockElectrocution
 22EnucleationRemoval of organ or tumor.
 25Foreign Body 
 28FractureBreaking of a bone or cartilage.
 30FreezingFrostbite and other effects or exposure to low temperature.
 31Hearing Loss or ImpairmentTraumatic only. A separate injury, not the sequelae of another injury.
 32Heat ProstrationHeat stroke, sun stroke, heat exhaustion, heat cramps and other effects of environmental heat. Does not include sunburn.
 34HerniaThe abnormal protrusion of an organ or part through the containing wall of its cavity.
 36InfectionThe invasion of a host by organisms such as bacteria, fungi, viruses, protozoa, insects or mold, with or without manifest disease.
 37InflammationThe reaction of tissue to injury characterized clinically by heat, swelling, redness and pain.
 40LacerationCut, scratches, abrasions, superficial wounds, calluses. Wound by tearing.
 41Myocardial InfarctionHeart attack, heart conditions, hypertension; the inadequate blood flow to the muscular tissue of the heart.
 42Poisoning - 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 or radiation, pneumoconiosis, corrosive effects of chemicals, skin surface irritations, septicemia or infected wounds.
 43PunctureA hole made by the piercing from a pointed
instrument.
 46Rupture 
 47SeveranceSeparation, division or take off.
 49SprainInternal derangement, a trauma or wrenching of a
joint, producing pain and disability depending
upon degree of injury of ligaments.
 52StrainInternal derangement, the trauma to the muscle or
the musculotendinous unit from violent
contraction or excessive forcible stretch.
 53SyncopeSwooning, fainting, passing out; no other injury.
 54AsphyxiationStrangulation, drowning
 55VascularCerebrovascular and other conditions of
circulatory systems, NOC. Excludes: heart and
hemorrhoids. Includes: strokes, varicose veins -
non-toxic.
 58Vision Loss 
 59All Other Specific Injuries, NOC 
II.Occupational
Disease or
Cumulative Injury
  
 60Dust Disease, NOCAll other pneumoconiosis.
 61AsbestosisLung disease, a form of pneumoconiosis, resulting from protracted inhalation of asbestos particles.
 62Black LungThe chronic lung disease or pneumoconiosis found in coal miners.
 63ByssinosisPneumoconiosis of cotton, flax and hemp workers.
 64SilicosisPneumoconiosis resulting from inhalation of silica (quartz) dust.
 65Respiratory DisordersGasses, fumes, chemicals, etc.
 66Poisoning - Chemical
(Other Than Metals)
Man-made or organic
 67Poisoning - MetalMan-made
 68DermatitisRash, 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. Do 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.
 69Mental DisorderA 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.
 70RadiationAll forms of damage to tissue, bones or body fluids produced by exposure to radiation.
 71All Other Occupational
Disease Injury, NOC
 
 72Loss of Hearing 
 73Contagious Disease 
 74Cancer 
 75AIDS 
 76VDT - Related DiseasesVideo display terminal diseases other than carpal tunnel syndrome.
 77Mental Stress 
 78Carpal Tunnel SyndromeSoreness, 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.
 79Hepatitis C 
 80All Other Cumulative Injury, NOC 
 83COVID-19 
III.Multiple Injuries  
 90Multiple Physical Injuries Only 
 91Multiple Injuries Including
Both Physical and Physiological
 


Injury Description Codes – Cause of Injury
 CodeCause of InjuryNarrative Description
I.Burn or Scald – Heat or Cold Exposures – Contact With  
 01Chemicals 
 02Hot Objects or Substances 
 03Temperature Extremes 
 04Fire or Flame 
 05Steam or Hot Fluids 
 06Dust, Gases, Fumes or Vapors 
 07Welding Operation 
 08Radiation 
 11Cold Objects or Substances 
 14Abnormal Air Pressure 
 84Electrical Current 
 09Contact With, NOC 
II.Caught In, Under or Between  
 10Machine or Machinery 
 12Object Handled 
 20Collapsing Materials (Slides of Earth) Either man-made or natural. 
 13Caught In, Under or Between, NOC
III.Cut, Puncture, Scrape – Injured By  
 15Broken Glass 
 16Hand Tool, Utensil; Not Powered 
 17Object Being Lifted or Handled 
 18Powered Hand Tool, Appliance 
 19Caught, Puncture, Scrape, NOC 
IV.Fall, Slip or Trip  
 25From Different Level (Elevation)Off wall, catwalk, bridge, etc.
 26From Ladder or Scaffolding 
 27From Liquid or Grease Spills 
 28Into OpeningsShafts, excavations, floor openings, etc.
 29On Same Level 
 30Slipped, Did Not Fall 
 32On Ice or Snow 
 33On Stairs 
 31Fall, Slip or Trip, NOC 
V.Motor Vehicle  
 40Crash of Water Vehicle 
 41Crash of Rail Vehicle 
 45Collision or Sideswipe with Another VehicleBoth vehicles in motion
 46Collision with a Fixed ObjectStanding vehicle or stationary object
 47Crash of Airplane 
 48Vehicle UpsetOverturned or jackknifed
 50Motor Vehicle, NOC 
VI.Strain or Injury By  
 52Continual Noise 
 53Twisting 
 54Jumping 
 55Holding or Carrying 
 56Lifting 
 57Pushing or Pulling 
 58Reaching 
 59Using Tool or Machinery 
 61Wielding or Throwing 
 97Repetitive MotionCarpal Tunnel Syndrome
 60Strain or Injury By, NOC
VII.Striking Against or Stepping On  
 65Moving Part of Machine 
 66Object Being Lifted or Handled 
 67Sanding, Scraping, Cleaning Operation 
 68Stationary Object 
 69Stepping on Sharp Object 
 70Striking Against or Stepping On, NOC
VIII.Struck or Injured By (includes Kicked, Stabbed, Bit, Etc.)  
 74Fellow Worker; PatientNot in act of a crime.
 75Falling or Flying Object 
 76Hand Tool or Machine in Use 
 77Motor Vehicle 
 78Moving Parts of Machine 
 79Object Being Lifted or Handled 
 80Object Handled By Others 
 85Animal or Insect 
 86Explosion or Flare Back 
 81Struck or Injured, NOCIncludes kicked, stabbed, bit, etc.
IX.Rubbed or Abraded By  
 94Repetitive MotionCallous, blister, etc.
 95Rubbed or Abraded, NOC
X.Miscellaneous Causes  
 82Absorption, Ingestion or Inhalation, NOC 
 83Pandemic 
 87Foreign Matter (Body) in (Eyes) 
 88Natural Disaster 
 89Person in Act of a Crime (Other Than Gunshot)Robbery or criminal assault
 90Other Than Physical Cause of Injury 
 93Gunshot 
 91Mold 
 96Terrorism 
 98Cumulative, NOCAll Other
 99Other - Miscellaneous, NOC