For those filings made in accordance with 11 NCAC 10 .1102(15), supporting information shall be presented as follows:

1. (1) Reference Filing Adoption Form:

   1. (a) Insurer's name.
   2. (b) Contact person for filing.
   3. (c) Title of contact person.
   4. (d) Phone number.
   5. (e) Insurer's FEIN.
   6. (f) Insurer's file number.
   7. (g) Department file number.
   8. (h) NCRB reference filing number.
   9. (i) Effective date.
   10. (j) Insurer's proposed effective date (if different from NCRB effective date).
   11. (k) Insurer's approximate market share of North Carolina written premium.
   12. (l) Whether the multiplier is applicable to this filing only or to subsequent reference filings.
   13. (m) Statement of accuracy of information.
   14. (n) Signature of company official.
   15. (o) Date signed.

2. (2) Summary of Supporting Data Form:

   1. (a) Statement of whether the filing applies uniformly to all workers' compensation classes.

   2. (b) Loss costs modification:

      1. (i) Without modification (factor equals 1.000).
      2. (ii) With modification (supporting documentation required).
   3. (c) Loss costs modification factor.

   4. (d) Selected expenses (attach Expense Provision Exhibit):

      1. (i) Commission and brokerage.
      2. (ii) Other acquisition.
      3. (iii) General expenses.
      4. (iv) Taxes, licenses, fees, loss based assessments.
      5. (v) Profit, contingencies, credit for investment income.
      6. (vi) Other.
      7. (vii) Total (i+ii+iii+iv+v+vi).
   5. (e) Development of Expected Loss and Loss Adjustment Expense (Target Cost) Ratio: Expressed in decimal form: 1.000-(d)(vii).
   6. (f) Overall effect of expense constant and minimum premiums: Expressed in decimal form, i.e., 1.2% overall effect would be 0.988.
   7. (g) Overall effect of size-of-risk discounts plus expense gradation recognition in retrospective rating: Expressed in decimal form, i.e., 8.6% average discount would be 0.914.
   8. (h) Provision for loss based assessments: See NCRB Reference Filing, Exhibit II.
   9. (i) Company formula loss costs multiplier (b)(ii) x (1.000 - h)/ [(g) - (d)(vii)] x (f).
   10. (j) Company selected loss costs multiplier. Explain any differences between (i) and (j).
   11. (k) Rate level changes for the coverages to which this page applies.
   12. (l) Statement of whether the insurer is amending the minimum premium formula.
   13. (m) Statement of whether the insurer is amending the expense constant(s).
   14. (n) Statement of whether the insurer is changing the premium discount schedules.
   15. (o) If the answer to (l), (m), or (n) is yes, documentation is required.

3. (3) Expense Provisions Exhibit: For the following items, the insurer shall provide the three most recent years, the average, industry average, and the selected:

   1. (a) Commissions and brokerage.
   2. (b) Other acquisition.
   3. (c) General expenses.
   4. (d) Taxes, licenses, fees, and loss based assessments.

   5. (e) Profit, contingencies, and investment income:

      1. (i) Profit and contingencies.
      2. (ii) Credit for investment income.
   6. (f) Other.

   7. (g) Total (a+b+c+d+e+f).

      The insurer shall indicate if the insurer's actual expense ratios are North Carolina, countrywide, or other (explain); and if the insurer's actual expense ratios are a percent of standard premium, percent of net premium, or other (explain). The insurer shall explain if the selected provisions differ from the average for reasons other than rounding.

History Note: Authority G.S. 58-2-40; 58-36-15; 58-36-100;
Eff. February 1, 1996;
Temporary Amendment Eff. December 1, 1999;
Amended Eff. July 1, 2000;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 3, 2017.