Ncci Erm 6 Form PDF Details

If you are a business owner, then you know that there are a lot of forms and documents that need to be filed with the government. One of the most important forms to file is the Ncci Erm 6 form. This form is used to report your company's risk management activities. Keep reading to learn more about what this form is and why it is important. The National Council on Compensation Insurance (NCCI) ERM 6 Form is a document that business owners use to report their company's risk management activities. This form is important because it helps the government understand how businesses are mitigating risks and what measures they are taking to protect their employees and customers.

Listed here, you can see some information regarding ncci erm 6 form PDF. It's going to provide you with the rough time you'll need to fill in the form and some further details.

QuestionAnswer
Form NameNcci Erm 6 Form
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesncci inclusion form virginia, ncci form 24 1b, erm 6 form, ncci 2021

Form Preview Example

NON-AFFILIATE FORMAT

ERM-6 FORM

WORKERS COMPENSATION EXPERIENCE RATING

FOR NON-AFFILIATE DATA

 

 

 

 

 

 

 

 

 

 

 

EFFECTIVE 01 DEC 2003

 

 

 

 

 

 

 

NAME OF RISK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS OF RISK

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP

 

 

RISK IDENTIFICATION NO.

 

 

 

 

EFFECTIVE DATE OF RATING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEDERAL IDENTIFICATION NUMBER

 

 

 

 

STATE OF COVERAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Coverage Period

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1)

(2)

(3)

 

 

(4)

 

(5)

 

 

(6)

(7)

 

(8)

 

Effective

Expiration

 

 

 

 

 

 

Claim

 

Injury

Open/Closed

Incurred Losses

Month/Day/

Month/Day/

Class

 

 

 

 

Identification

 

Type

–Final

 

(Paid plus

 

Year

 

 

Year

Code

 

Payroll

 

Number Assigned

 

Code

(O/F)

 

Reserves)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE FOLLOW THE INSTRUCTIONS ON THE BACK PAGE FOR COMPLETING THIS WORKSHEET, AND RETURN IT TO NCCI PRIOR TO THE RATING EFFECTIVE DATE.

ERM-6 (Rev. 12/03)

Page 1 of 2

© 2002 National Council on Compensation Insurance, Inc.

NON-AFFILIATE FORMAT

INSTRUCTIONS FOR SUBMITTING EXPERIENCE RATING DATA

PAYROLL AND LOSSES MUST BE ROUNDED TO THE NEAREST WHOLE DOLLAR.

COLUMN 1

Fill in the effective month, day and year of the period for which information will be provided. A total of three

 

years of experience can be included in the rating, not including the year immediately prior to the effective

 

date of this rating. Each year’s payroll and losses should be listed separately.

COLUMN 2

Fill in the expiration month, day and year of the period for which information will be provided.

COLUMN 3

Fill in the NCCI classification codes(s) that best describes your type of business. If you have any questions

 

regarding these classifications, please contact Customer Service at 800-NCCI-123.

COLUMN 4

Fill in the payroll amounts associated with the classification code(s) for each year being reported.

COLUMN 5

Provide the claim number used for internal record keeping should you desire this information on the

 

modification worksheet. If claim numbers are not used for internal record keeping, leave column blank.

COLUMN 6

Fill in the appropriate injury type code (see following list). Only one injury type code is applicable per claim.

 

Medical only claims should be listed as a “6,” but claims that include both medical and disability or death

 

benefits should be listed under the applicable disability or death code, such as “5” (Temporary Total or

 

Temporary Partial Disability). Injury types must be noted for each entry.

 

1 = Death

6 = Medical Only

 

2 = Permanent Total Disability

7 = Contract Medical or Hospital Allowance

 

5 = Temporary Total or Temporary Partial Disability

9 = Permanent Partial Disability

COLUMN 7

Indicate whether the claim is open or closed/final by placing an O or F in the column.

COLUMN 8

In Column 8, fill in the sum of incurred (paid plus reserved) losses per row. If no claims occurred, place a 0

 

in that space. Claims must be reported individually regardless of claim amount.

The experience rating will be completed in accordance with the NCCI Experience Rating Plan Manual for Workers Compensation and Employers Liability Insurance. However, because we do not verify the accuracy of the data submitted by non-affiliates, the modification factor will be issued with a disclaimer.

Name of the self-insured entity requesting the rating _______________________________________________________________________________

Name of the entity submitting the data (if different) _________________________________________________________________________________

Address _______________________________________________________________________________________ City _____________________

State ___________ Zip _________________ Phone ________________________ Fax __________________________ E-mail _____________

AGREEMENT

We hereby certify that the information given in this report is correct to the best of our knowledge and belief. BY SUBMISSION OF THIS INFORMATION, WE REQUEST THAT NCCI PRODUCE EXPERIENCE MODIFICATION FACTORS ON EACH OF THE RISKS LISTED AND AGREE TO PAY THE FEES FOR THIS SERVICE. In consideration of NCCI’s agreement to produce the requested experience modifications, we release and discharge NCCI, its officers, directors, employees and agents from all liability (except for gross negligence) in connection with the production or application of the same.

The person signing this agreement certifies that he/she has the authority to execute this agreement on behalf of the self-insured entity requesting the rating. Authorized signers include the risk, the group self-insured and the TPA

ONLY.

Signed __________________________________________

Date _________________________________

Printed Name of Signer _____________________________

Title __________________________________

 

ERM-6 (Rev. 12/03)

Page 2 of 2

 

Guide to the ERM-6 Form—

Workers Compensation Experience Rating for Self-Insureds

ERM-6 Form Key Definitions:

Risk Identification No.—A 9-digit number that NCCI assigns to each rated insured.

State of Coverage—The state for which the policy was written; this is not necessarily the state in which the insured is located.

Effective Date of Rating—This is the first day of the rating period for an experience rating modification. This date is based on the effective date of the most current policy that ran a full year. For example, if last year’s policy effective date was 4/4/03, then the effective date of the experience rating would be 4/4/04.

What Fits on a Rating—A total of three years of experience can be included on a rating. Do not include the year immediately prior to the effective date of the rating.

For example, payroll and losses that would be included on a 4/4/04 rating would be:

4/4/00–4/4/01

4/4/01–4/4/02

4/4/02–4/4/03

The 4/4/03–4/4/04 experience will not be included on an experience rating effective 4/4/04.

Please Keep the Following in Mind When Preparing an ERM-6 Form:

It is extremely important that everything be filled out completely and accurately. If handwritten, please print clearly.

Payroll—It is not possible to have losses without payroll. All payroll amounts must be submitted in whole dollars only (e.g., correct $1; incorrect $1.25).

Each payroll amount must have the appropriate class code assigned to it.

Claims—Remember to fill out the Injury Code field for claims information, including whether the claim is open (O) or closed/final (F).

When consolidating small claims ($2,000 or less), remember to specify whether they are Injury Code 5 or 6, and put an asterisk (*) in the open/closed column.

Each claim amount must be submitted in whole dollars only.

1

When submitting multiple pages of ERM-6 data, each page must have the following information printed at the top:

Risk Name

Risk ID No.

Effective Date of Rating

Policy Effective/Expiration Date

State of Coverage

Loss runs, worksheets, or any other forms are not accepted in lieu of the approved NCCI ERM-6 form.

All information must be submitted on the approved NCCI ERM-6 form. No other attachments can be accepted (e.g., Excel spreadsheets).

Information to Accompany Request:

If the insured has current coverage on file with NCCI, please provide a letter of authority on the current carrier’s letterhead.

If no current coverage is on file with NCCI, please include a $75 payment via credit card, check, or account and site number.

You can also fax the ERM-6 form to our Customer Service Center at 561-893-1191.

2

ERM-6 Form in PDF Format

The ERM-6 form is now available to our customers in a PDF document that can be updated. You can now electronically enter Workers Compensation Experience Rating Information for Self- Insureds directly onto the form.

This is a filed and approved form. NCCI has protected the content in order to avoid any changes to the document. The form can only be printed; it cannot be saved to your system. Please print a

copy for your records.

Helpful Hints for Completing the ERM-6 Form in the PDF Format:

In order to easily navigate through the form, use your Mouse or Tab key. (Please note: The Enter key will bring you to the end of the form.)

You will be able to enter information in the allotted space provided on the form. Please be aware that if the information you have typed exceeds the space provided, not all the information will be viewed on the form.

You will need to print out the form in order to obtain the authorized signature of the person who has the authority to execute this agreement on behalf of the self-insured entity requesting the rating.

If you do not already have Adobe® Acrobat® installed, you can download the latest version of Acrobat® Reader® for free from the Adobe Web site at adobe.com.

3

 

EXPERIENCE RATING PLAN MANUAL

 

 

 

 

 

 

 

 

 

 

Page A-5

 

APPENDIX

 

 

 

 

 

 

 

 

Issued January 14, 2002

 

 

 

 

 

 

Original Printing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NON-AFFILIATE FORMAT

 

 

 

 

 

 

 

 

WORKERS COMPENSATION EXPERIENCE RATING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR SELF-INSUREDS

 

 

 

 

 

 

 

 

 

 

 

NAME OF RISK ABC Inc

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EXAMPLE

 

 

 

 

 

STATE FL

 

ADDRESS OF RISK 88 Mount Vernon Avenue

 

 

CITY

Wellington

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP 33414

 

 

RISK IDENTIFICATION NO. 091 197 188

 

EFFECTIVE DATE OF RATING 4/14/2004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEDERAL IDENTIFICATION NUMBER 123123123

 

STATE OF COVERAGE

 

Florida

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Coverage Period

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1)

(2)

(3)

 

(4)

(5)

 

(6)

 

(7)

 

(8)

 

 

Effective

Expiration

 

 

 

 

 

Claim

Injury

 

Open/Closed

 

 

 

Month/Day/

Month/Day/

Class

 

 

 

 

Identification

Type

 

 

 

–Final

 

Incurred Losses

 

 

 

Year

 

 

Year

Code

 

 

Payroll

Number Assigned

Code

 

 

 

(O/F)

 

(Paid plus Reserves)

 

 

4/14/2000

4/14/2001

8810

 

1,000,000

No.1

6

 

*

 

5

 

 

 

 

 

 

 

 

 

 

4902

 

88,000,000

1969

 

 

5

 

 

 

F

 

20,000

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1986

 

 

5

 

 

 

O

 

32,000

 

 

 

4/14/2001

4/14/2002

8810

 

1,500,000

No. 2

6

 

*

 

97

 

 

 

 

 

 

 

O

 

50,000

 

 

 

 

1954

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

4902

 

100,000,000

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8810

 

2,000,000

1994

 

 

5

 

 

 

F

 

20,500

 

 

 

4/14/2002

4/14/2003

 

 

 

 

*

 

141

 

 

 

 

 

 

6

 

 

 

 

 

 

No. 3

 

 

 

 

 

 

 

 

 

 

 

4902

 

200,000,000

5

 

 

 

F

 

1,000

 

 

 

 

 

 

 

 

 

 

1971

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

O

 

5,000

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1972

 

 

 

 

 

F

 

10,000

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1978

 

 

 

 

 

O

 

15,000

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1979

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE FOLLOW THE INSTRUCTIONS ON THE BACK PAGE FOR COMPLETING THIS WORKSHEET, AND RETURN IT TO NCCI PRIOR TO THE RATING EFFECTIVE DATE.

ERM-6 (Rev. 99)

NC1816(0628d)

© 1995, 1999, 2002 National Council on Compensation Insurance, Inc.

1/02

Page A-6

 

EXPERIENCE RATING PLAN MANUAL

1st Reprint

Issued February 18, 2000

 

 

APPENDIX

 

 

 

 

 

 

 

NON

-AFFILIATE FORMAT

 

EXAMPLE

PAYROLL AND LOSSES MUST BE ROUNDED TO THE NEAREST WHOLE DOLLAR.

COLUMN 1

Fill in the effective month, day and year of the period for which information will be provided. A total of three

 

years of experience can be included in the rating, not including the year immediately prior to the effective date

 

of this rating. Each year’s payroll and losses should be listed separately.

COLUMN 2

Fill in the expiration month, day and year of the period for which information will be provided.

COLUMN 3

Fill in the NCCI classification codes(s) that best describes your type of business. If you have any questions

 

regarding these classifications, please contact Customer Service at 800-NCCI 1-2-3.

COLUMN 4

Fill in the payroll amounts associated with the classification code(s) for each year being reported.

COLUMN 5

Provide the claim number used for internal record keeping should you desire this information on the

 

modification worksheet. If claim numbers are not used for internal record keeping, leave column blank.

COLUMN 6

Fill in the appropriate injury type code (see following list). Only one injury type code is applicable per claim.

 

Medical only claims should be listed as a “6,” but claims that include both medical and disability or death

 

benefits should be listed under the applicable disabililty or death code, such as “5” (Temporary Total or

 

Temporary Partial Disability). Injury types must be noted for each entry.

 

1 = Death

6 = Medical Only

 

2 = Permanent Total Disability

7 = Contract Medical or Hospital Allowance

 

5 = Temporary Total or Temporary Partial Disability

9 = Permanent Partial Disability

COLUMN 7

Indicate whether the claim is open or closed/final by placing an O or F in the column.

COLUMN 8

In Column 8, fill in the sum of incurred (paid plus reserved) losses per row. If no claims occurred, place a 0 in

 

that space. Claims must be reported individually regardless of claim amount.

The experience rating will be completed in accordance with the NCCI Experience Rating Plan Manual for Workers Compensation and Employers Liability Insurance. However, because we do not verify the accuracy of the data submitted by non-affiliates, the modification factor will be issued with a disclaimer.

Name of the self-insured entity requesting the rating ABC Inc ___________________________________________________________________________

Name of the entity submitting the data (if different) ___________________________________________________________________________________

Address 88 Mount Vernon Avenue __________________________________________________________________ City Wellington_______________

State Florida_______ Zip 33414-7630 __________

Phone 1-800-555-1212 ________ Fax 1-888-729-1234 ____________

E-mail __________

agibson@abcinc.com

AGREEMENT

We hereby certify that the information given in this report is correct to the best of our knowledge and belief. BY SUBMISSION OF THIS INFORMATION, WE REQUEST THAT NCCI PRODUCE EXPERIENCE MODIFICATION FACTORS ON EACH OF THE RISKS LISTED AND AGREE TO PAY THE FEES FOR THIS SERVICE. In consideration of NCCI’s agreement to produce the requested experience modifications, we release and discharge NCCI, its officers, directors, employees and agents from all liability (except for gross negligence) in connection with the production or application of the same.

The person signing this agreement certifies that he/she has the authority to execute this agreement on behalf of the self-insured entity requesting the rating. Authorized signers include the risk, the group self-insured and the TPA ONLY.

Signed “Please print form to include signature”_______________

Date May 24,2004________________________________

Printed Name of Signer Alfred Gibson IV ____________________

Title President & CEO ____________________________

© 1988, 1999 National Council on Compensation Insurance, Inc.

2/00

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