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Home My WebLink About000260.tiff Arthur J. Gallagher & Co. - Denver October 31, 2002 National Council on Comprehensive Insurance Attn: Self Insured Rating Division P.O. Box 3098 Boca Raton, FL 33431--0998 Re: Weld County, Colorado Risk ID#: 054001738 Dear Representative: Enclosed is the revised worksheet/ERM-6 form for the captioned self-insured risk for calculating the modification factor, effective 1/1/03. Please note I have applied a $5,000 deductible to each claim, per the email from Jessica Morgenthal (attached). Also, I have enclosed a copy of the letter Weld County, CO received from the Department of Labor and Employment explaining the $5,000 deductible policy. Should you require any other information, please contact me at 720-528-3642. The Arthur J. Gallagher, Denver Branch's account number is 887000, Site #5961. My requestor ID number is 736725. Sincerely, obbie Taylor Account Representative Enclosures Cc: Ty Pixler, Sr. Account Manager t.....--1161-1Warden, Weld County, CO 7900 East Union Avenue, Suite 200 Denver,CO 80237-2737 303.773.9999 Fax 303.773.9776 Toll Free 800.333.3231 260 www.ajg.com Date: 10/31/02 Non-Affiliate Format Effective October 1, 1999 WORKERS COMPENSATION EXPERIENCE RATING FOR SELF-INSUREDS Name of Risk:Weld County State: Colorado Address of Risk: P.O.Box 758,Greeley,CO 80632 Risk Identification No.: 54001738 Effective Date: 1/1/03 Federal ID#: 1 2 3 4 5 6 7 8 Actual Incurred Effective Expiration Class Injury Type Open/Closed Incurred Losses Losses Less Year/Mo Year/Mo Code Payroll Claim Number Code -Final (Paid+Reserves)$5,000 Deductil 1/1/99 12/31/99 5506 3,506,488 099WLD0003 6 F $291 7382 221,540 099WLD001 6 F $142 7720 9,087,574 099WLD002 6 F $271 8742 1,931,748 099WLD003 6 F $46 8810 10,841,444 099WLD004 5 F $19,004 $14,( 8820 1,359,210 099WLD0041 6 F $59 8831 55,863 099WLD005 5 O $69,957 $64,£ 8832 1,728,884 099WLD0067 6 F $250 8868 1,788,399 099WLD0118 6 F $1,383 9014 59,221 099WLD012 9 F $7,694 $2,E 9015 879,986 099WLD0210 6 F $98 9101 510,602 099WLD025 1 F $8,269 $3,E 9410 1,541,471 099WLD027 5 O $36,388 $31,: 33,512,430 099WLD045 5 F $1,173 099WLD0491 6 F $778 099WLD0512 6 F $185 099WLD059 5 F $432 099WLD062 5 F $12,397 $7,: 099WLD063 5 F $2,894 099WLD068 5 F $24,837 $19,E 099WLD069 9 F $3,583 099WLD070 9 F $26,383 $21,: 099WLD0700 6 F $84 099WLD071 5 F $18,358 $13,: 099WLD072 5 O $9,676 $4,E 099WLD0731 6 F $130 099WLD074 9 F $17,038 $12,C 099WLD1040 6 F $52 099WLD1227 6 F $87 099WL01253 6 F $184 099WLD1254 6 F $368 099WLD1255 6 F $1,159 099WLD1323 6 F $361 099WLD1341 6 F $346 099WLD1447 6 F $163 099WLD1448 5 O $63,330 $58,3 099WLD1524 5 F $2,254 099WLD1597 6 F $59 099WLD2151 6 F $549 099WLD2163 6 F $6 099WLD2189 6 F $218 099WLD2190 6 F $2,302 099WLD2191 9 F $6,937 $1,5 099WLD2333 6 F $244 099WLD3147 6 F $68 Date: 10/31/02 Non-Affiliate Format Effective October 1, 1999 1 2 3 4 5 6 7 8 Actuallncurrec Effective Expiration Class Injury Type Open/Closed Incurred Losses Losses Less Year/Mo Year/Mo Code Payroll Claim Number Code -Final (Paid+Reserves'$5,000 Deductil 099WLD350 5 F $601 099WLD4000 6 F $289 099WLD4001 6 F $291 099WLD519 6 F $156 099WLD610 9 O $26,354 $21,: 099WLD612 6 F $551 099WLD8814 6 F $59 099WLD9439 6 F $143 099WLD9842 6 F $59 $368,986 $276,E 1/1/00 12/31/00 5506 3,829,170 200WLD001 6 F $142 7382 242,425 200WLD002 6 F $190 7720 9,741,867 200WLD003 6 F $467 8742 2,174,362 200WLD004 6 F $4,668 8810 11,937,348 200WLD005 6 F $160 8820 1,454,960 200WLD006 6 F $922 8831 59,244 200WLD007 6 F $2,882 8832 1,753,037 200WLD008 5 F $7,198 $2,' 8868 1,857,046 200WLD009 6 F $175 9014 66,797 200WLD010 6 F $228 9015 996,471 200WLD011 5 F $21,184 $16,' 9101 464,866 200WLD012 6 F $659 9410 1,710,242 200WLD013 6 F $176 36,287,835 200WLD014 6 F $883 200WLD015 6 F $705 200WLD016 6 F $73 200WLD017 6 F $1,716 200WLD018 6 F $230 200WLD019 6 F $307 200WLD020 6 F $106 200WLD021 6 F $425 200WLD022 6 F $123 200WLD023 6 F $1,756 200WLD025 6 F $7 200WLD026 6 F $7 200WLD027 6 F $7 200WLD028 6 F $418 200WLD029 6 F $217 200WLD030 6 F $317 200WLD031 6 F $709 200WLD032 6 F $227 200WLD033 5 F $4,543 200WLD034 6 F $706 200WLD035 5 F $1,836 200WLD036 6 F $137 200WLD037 6 F $204 200WLD038 6 F $398 200WLD039 6 F $126 200WLD040 6 F $110 200WLD041 6 F $545 200WLD042 6 F $207 200WLD043 5 O $25,432 $20,4 200WLD044 5 F $569 Date: 10/31/02 Non-Affiliate Format Effective October 1, 1999 1 2 3 4 5 6 7 8 Actuallncurrec Effective Expiration Class Injury Type Open/Closed Incurred Losses Losses Less Year/Mo Year/Mo Code Payroll Claim Number Code -Final (Paid+Reserves`$5,000 Deductil 200WLD045 6 F $366 200WLD046 5 F $10,059 $5,( 200WLD047 6 F $87 200WLD048 5 O $46,971 $41,≤ 200WLD049 5 F $233 200WLD050 6 F $484 200WLD051 6 F $9,429 $4,' 200WLD052 6 F $1,909 200WLO053 6 F $138 200WLD054 6 F $236 200WLD055 6 F $184 200WLD056 6 F $227 200WLD057 6 F $1,046 200WLD058 6 F $1,359 200WLD060 5 F $380 200WLD061 6 F $279 200WLD062 6 F $77 200WLD063 6 F $197 200WLD064 6 F $616 200WLD065 6 F $465 200WLD066 6 F $2,039 200WLD067 6 F $431 200WLD068 6 F $962 200WLD069 6 F $2,257 200WLD070 6 F $113 200WLD071 5 F $1,230 200WLD072 5 F $6,059 $1,( 200WLD073 6 F $649 200WLD074 6 F $6,365 $1,( 200WLD075 6 F $2,399 200WLD076 6 F $309 200WLD077 5 O $61,398 $56,: 200WLD078 6 F $1,953 200WLD079 6 F $230 200WLD080 6 F $1,025 200WLD081 5 F $24,397 $19,( 200WLD082 6 F $2,694 200WLD083 6 F $555 200WLD084 6 F $149 200WLD085 6 F $425 200WLD086 5 F $225 200WLD087 6 F $894 200WLD088 6 F $535 200WLD089 5 F $12,517 $7„ 200WLD090 6 F $261 200WLD091 6 F $2,430 200WLD092 6 F $1,306 200WLD093 6 F $309 200WLD094 6 F $222 200WLD095 6 F $266 200WLD096 5 F $2,669 200WLD097 6 F $5,166 $1 200WLD098 6 F $3,945 200WLD099 5 F $6,556 $1,E Date: 10/31/02 Non-Affiliate Format Effective October 1, 1999 1 2 3 4 5 6 7 8 Actuallncurrec Effective Expiration Class Injury Type Open/Closed Incurred Losses Losses Less Year/Mo Year/Mo Code Payroll Claim Number Code -Final (Paid+Reserves`$5,000 Deducti 200WLD101 6 F $361 200WLD102 6 F $1,453 200WLD103 6 F $205 200WLD104 6 F $154 200WLD105 6 F $4,390 200WLD106 6 F $227 200WLD108 6 F $512 200WLD109 6 F $315 200WLD110 6 F $378 200WLD111 6 F $660 200WLD112 6 F $280 200WLD113 6 F $561 200WLD114 6 F $344 200WLD115 6 F $1,184 $320,802 $177,'' 1/1/01 12/31/01 5506 4,029,734 201WLD001 6 F $509 7382 250,876 201WLD002 6 F $201 7720 10,827,608 201WLD003 5 F $15,777 $10,. 8742 2,292,428 201WLD004 5 O $34,043 $29,1 8810 12,729,640 201WLD005 6 F $366 8831 52,151 201WLD006 6 F $197 8832 2,031,003 201WLD007 6 F $2,390 8868 1,037,636 201WLD008 6 O $6,672 $1,E 9014 78,000 201WLD009 5 F $840 9015 1,028,921 201WLD010 6 F $388 9101 491,872 201WLD011 6 F $3,862 9410 1,859,400 201WLD012 6 F $486 36,709,269 201WLD013 6 F $79 201WLD014 6 F $684 201WLD015 6 F $1,104 201WLD016 6 F $2,424 201WLD017 6 F $1,945 201WLD018 6 F $298 201WLD019 6 F $260 201WLD020 6 F $559 201WLD021 6 F $491 201WLD022 6 F $545 201WLD023 5 F $8,190 $3: 201WLD024 6 F $256 201WLD025 6 F $1,287 201WLD026 5 F $1,354 201WLD027 6 F $290 201WLD029 6 F $803 201WLD030 6 F $265 201WLD031 6 F $160 201WLD032 6 F $275 201WLD033 5 F $1,809 201WLD034 6 F $1,079 201WLD035 6 O $2,500 201WLD036 6 F $184 201WLD037 6 O $700 201WLD038 5 O $134,694 $129,E 201WLD039 6 F $1,235 • Date: 10/31/02 Non-Affiliate Format • Effective October 1, 1999 1 2 3 4 5 6 7 8 Actuallncurrec Effective Expiration Class Injury Type Open/Closed Incurred Losses Losses Less Year/Mo Year/Mo Code Payroll Claim Number Code -Final (Paid+Reserves)$5,000 Deducti 201WLD040 6 F $244 201WLD041 6 O $1,000 201WLD042 6 F $75 201WLD043 5 F $724 201WLD044 6 F $2,008 201WLD046 6 F $1,791 201WLD047 5 O ' $10,637 $5,E 201WLD049 6 F $348 201WLD050 6 F $594 201WLD052 6 F $3,118 201WLD053 6 F $429 201WLD055 6 F $196 201WLD056 5 O $25,710 $20,' 201WLD057 6 F $4,260 201WLD058 6 F $352 201WLD061 6 F $302 201WLD062 6 F $388 201WLD063 5 F $631 201WLD064 6 F $1,639 201WLD065 6 F $944 201WLD066 6 F $89 201WLD067 6 F $1,479 201WLD069 6 F $1,965 201WLD070 6 F $544 201WLD071 6 F $1,109 201WLD072 6 F $545 201WLD073 6 O $900 201WLD074 5 F $18,929 $13,5 201WLD075 6 F $1,463 201WLD076 6 F $89 201WLD077 6 F $1,802 201WLD078 5 O $84,993 $79,5 201WLD079 6 F $126 201WLD080 6 F $126 201WLD081 6 F $126 201WLD082 6 O $1,700 201WLD085 6 F $1,379 201WLD086 6 F $533 201WLD087 6 F $192 201WLD088 6 F $245 201WLD089 5 O $11,671 $6,E 201WLD090 5 F $1,414 201WLD091 6 F $1,559 201WLD092 6 O $700 201WLD093 6 F $258 201WLD094 5 O $4,346 201WLD095 6 F $164 201WLD096 6 F $346 201WLD097 6 F $184 201WLD098 6 F $497 201WLD099 5 O $19,474 $14,i 201WLD100 6 F $400 201WLD101 5 O $49,105 $44,' 201WLD102 6 F $594 Date: 10/31/02 Non-Affiliate Format • Effective October 1, 1999 1 2 3 4 5 6 7 8 Actuallncurrec Effective Expiration Class Injury Type Open/Closed Incurred Losses Losses Less Year/Mo Year/Mo Code Payroll Claim Number Code -Final (Paid+Reserves)$5,000 Deductil 201WLD103 6 F $267 201WLD104 6 F $251 201WLD105 6 F $366 201WLD106 6 F $459 201WLD107 6 O $3,500 201WLD108 6 F $2,882 201WLD109 6 F $250 201WLD110 5 F $3,916 201WLD111 6 F $230 201WLD112 6 F $58 201WLD114 5 F $2,492 201WLD115 6 F $343 201WLD116 6 F $316 201WLD117 6 O $1,000 201WLD118 6 F $1,366 201WLD119 5 F $164 201WLD120 6 F $495 201WLD121 6 F $1,090 201WLD122 5 O $14,256 $9,: 201WLD123 6 O $5,000 201WLD124 5 F $10,436 $5,4 201WLD125 6 F $982 201WLD126 6 F $100 201WLD127 5 O $38,933 $33,1 201WLD128 6 F $280 " 201WLD129 6 F $335 583,401 $408„ 1.I Page A-6 EXPERIENCE RATING PLAN MANUAL 2nd Reprint Effective October 1, 1999 APPENDIX 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 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 Weld County ____ tame of the entity submitting the data(if different) Address__ P.O. Box 758-- ------ __ City Gx_ee].ey- --- -------- State—CO ___ Zip-tea(}.3. 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 sig n I this agreement c rtifi s t e/she s the authority to execute this agreement on behalf of the self- insured entity eq esting t e r in t ri signers dude the risk,the group self-insured and the TPA ONLY. Signed -- - - � - ---- Date �_A2-z"6 2- Printed Name of Signer9Q. 1 jJL -_ ___ eiti Title_ [ [ TS _ cie_ A u// ©1988,1999 National Council on Compensation Insurance. Jessica_Morgenthal@ To: bobbie_taylor@ajg.com ncci.com cc: Subject: Re: 5,000 deduct when reporting ERM 6's for Colorado 10/29/02 02:00 PM Bobby - I hope this helps. Please take note to the information on the erm 6 at the bottom of Gerald's response. Jessica Morgenthal NCCI - Customer Service 561.893 .1205 - phone 561.893 .5291 - fax Forwarded by Jessica Morgenthal/BOCA/NCCI on 10/29/2002 04 :00 PM Gerald Ordoyne To: Jessica Morgenthal/BOCA/NCCI@NCCI 10/29/2002 cc: Paja Rafferty/BOCA/NCCI@NCCI, Robert Sey/BOLA/NCCI@NCCI 03:43 PM Subject: Re: 5,000 deduct when reporting ERM 6 's for Colorado (Document link: Jessica Morgenthal) I believe the answer to this question can be found in the Circular STAT-02-01 in the Impact Section: Reporting Under a Net or Gross Deductible Program If reporting in the URE format, report all indemnity/medical losses on a gross basis regardless of whether you are reporting under a net or gross deductible program. If reporting under a net deductible program, report the applicable deductible reimbursement in the Deductible Reimbursement Amount field on the Loss Record. NCCI will automatically reduce the loss by the deductible reimbursement when calculating the experience rating modification. If reporting under a gross deductible program, report the Deductible Reimbursement Amount field on the Loss Record using zeros (or leave blank if reporting on hard copy) . If reporting in the pre-URE format under a net deductible program, report the loss net of the deductible reimbursement. If reporting in the pre-URE format under a gross deductible program, losses should be reported gross. Since ERM6 is a pre-URE format, it would be up to the submitter to reduce each loss by the applicable deductible reimbursement amount prior to submitting to NCCI. Let me know if you have any other questions. Gerald Jessica Morgenthal To: Gerald Ordoyne/BOCA/NCCI@NCCI cc: Paja Rafferty/BOCA/NCCI@NCCI, Robert Sey/BOCA/NCCI@NCCI 10/29/2002 Subject: 5, 000 deduct when reporting ERM 6's for Colorado 01:17 PM Gerald - Can you let me know the protocol for the 5, 000 deduct. and how it needs to be reported on an ERM 6 for Colorado. ie: does the person reporting the ERM 6 deduct it before submitting the ERM 6 or does NCCI deduct it when we calculate it . . . If you have any concerns please feel free to call me. Thanks for your time, I really appreciate it. jessica x1205 • •• DEPARTMENT OF LABOR AND EMPLOYMENT J.ARMSTRONG pF'CO( DIVISION OF WORKERS'COMPENSATION EMPLOYER SERVICES ;zutive Director w'3 Py F4% a JEFFREY M.WELLS ti :L: �N O Two Park Central Suite 600 f4 I ' )`� * 1515 Arapahoe Street Deputy Executive Director V V ♦ Denver Colorado 80202-2117 (303)318-8650 MARY ANN WHITESIDE 'K J876 (303)318-8651 FAX Director October 11, 2002 Donald Warden Weld County Director Finance & Administration P.O. Box 758 Greeley, CO 80632 As you may have noticed, the calculation procedure for your State of Colorado Workers' Compensation surcharge report has changed. The calculation includes a hazard group discount that is based on a $5, 000 deductible. This means your surcharge is based on a premium equivalent to a policy with a $5, 00O deductible. Your surcharge calculation is also based on your workers' compensation experience rating, as developed by the National Council on Compensation Insurance (NCCI) . This rating is derived from an evaluation of the frequency and severity of your workers' compensation losses . Although all workers' compensation claims and costs must be reported by you to NCCI for this evaluation, Colorado regulations require that NCCI only consider those loss costs and claims above $5, 000 if the experience rating is developed using only Colorado payroll and claim information. If your company has no operations in other states, or if your company receives an NCCI mod for Colorado employees only, you may request NCCI to calculate your mod based on a $5, 000 deductible policy. If your company has its mod calculated using states in addition to Colorado you will have to contact NCCI at 1-800-622-4123 to determine if you can benefit from having your experience mod based on a $5, 000 deductible policy. sincerely, L,d43 aril/z.._. Bill Loften Revenue Assessment Officer Hello