Fill in a Valid Ncci Erm 6 Template

The NCCI ERM-6 Form is a document used for reporting workers' compensation experience rating data for non-affiliated entities. This form plays a crucial role in determining the experience modification factor, which can affect insurance premiums. To ensure accurate processing, it is important to complete the form thoroughly and submit it before the rating effective date.

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The NCCI ERM-6 form serves as a critical tool for businesses seeking to establish their workers' compensation experience rating, particularly for self-insured entities. This form captures essential data over a three-year period, excluding the most recent year, and provides a structured way to report payroll and loss information. Key sections of the form require details such as the name and address of the risk, the risk identification number, and the effective date of the rating. Each claim must be meticulously documented, including the type of injury, whether the claim is open or closed, and the total incurred losses. Accurate completion of the ERM-6 is vital, as it directly influences the experience modification factor, which can impact insurance premiums. Users must adhere to specific formatting guidelines, ensuring that payroll figures are rounded to whole dollars and that classification codes accurately reflect the nature of the business. Submitting this form correctly not only facilitates the rating process but also helps in managing overall insurance costs effectively.

Ncci Erm 6 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/

Class

Identification

Type

–Final

(Paid plus

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

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.

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.

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.

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					STATE FL

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
									No. 2			6		O		50,000
									1954			5		O		50,000
				4902		100,000,000						5


				8810		2,000,000			1994			5		F		20,500
4/14/2002		4/14/2003										5	*			141
												6
									No. 3			6
				4902		200,000,000			No. 3			5		F		1,000
				4902		200,000,000			1971			5		F		1,000
									1971			5		O		5,000
									1972			5		F		10,000
									1972			5		F		10,000
									1978			5		O		15,000
									1978			5		O		15,000
									1979			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)

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.

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 __________

[email protected]

AGREEMENT

Signed “Please print form to include signature”_______________	Date May 24,2004________________________________
Printed Name of Signer Alfred Gibson IV ____________________	Title President & CEO ____________________________

2/00

Click for Ncci Erm 6 File

File Breakdown

Fact Name	Description
Form Purpose	The ERM-6 form is used to report workers' compensation experience rating data for non-affiliates.
Effective Date	This form has been effective since December 1, 2003.
Data Requirements	A total of three years of experience data can be submitted, excluding the year immediately prior to the rating effective date.
Payroll Submission	All payroll amounts must be rounded to the nearest whole dollar when reported on the form.
Claim Reporting	Each claim must be reported individually, with specific codes indicating the type of injury and whether the claim is open or closed.
Governing Laws	The ERM-6 form is governed by the NCCI Experience Rating Plan Manual for Workers Compensation and Employers Liability Insurance.
Submission Instructions	Completed forms must be submitted to NCCI prior to the effective date of the rating, following the instructions provided on the back of the form.

Guide to Using Ncci Erm 6

Completing the NCCI ERM-6 form is a crucial step in submitting your workers' compensation experience rating data. This form requires specific information about your business and its claims history. Accuracy is essential, as the data you provide will directly impact your experience modification factor.

Begin by filling in the Name of Risk and Address of Risk sections. Include the City, State, and ZIP code.
Enter the Risk Identification No. assigned by NCCI.
Provide the Effective Date of Rating as the first day of the rating period.
Fill in the Federal Identification Number and the State of Coverage.
Indicate the Coverage Period by entering the effective and expiration dates.
In Column 1, input the effective month, day, and year for each reporting year.
In Column 2, enter the expiration month, day, and year for each reporting year.
In Column 3, fill in the NCCI classification code(s) that best describe your business type.
For Column 4, report the payroll amounts associated with each classification code for the years being reported.
In Column 5, provide the claim number if applicable; leave it blank if not used.
Enter the appropriate Injury Type Code in Column 6. Use the specified codes for different types of claims.
Indicate in Column 7 whether the claim is open (O) or closed/final (F).
In Column 8, sum the incurred losses (paid plus reserved) for each claim. Enter 0 if no claims occurred.
Complete the section for the Name of the self-insured entity requesting the rating and, if different, the Name of the entity submitting the data.
Fill in the Address, City, State, ZIP, Phone, Fax, and E-mail information.
Sign and date the agreement section, ensuring the signer has the authority to execute the agreement.

After completing the form, review all entries for accuracy. It is essential to submit the form to NCCI before the rating effective date. Ensure that no additional documents or attachments are included, as only the completed NCCI ERM-6 form will be accepted.

Get Answers on Ncci Erm 6

What is the purpose of the NCCI ERM-6 form?

The NCCI ERM-6 form is used to report workers' compensation experience rating data for self-insured entities. This form helps determine the experience modification factor, which affects the premium rates for workers' compensation insurance. By submitting accurate data, businesses can ensure they receive a fair assessment of their claims history and associated costs.
How should I fill out the payroll and losses on the ERM-6 form?

When completing the ERM-6 form, payroll and losses must be rounded to the nearest whole dollar. Each year’s payroll and losses should be reported separately for a total of three years, excluding the year immediately prior to the effective date of the rating. Be sure to assign the correct NCCI classification code to each payroll amount to ensure accurate reporting.
What types of claims need to be reported on the ERM-6 form?

All claims must be reported individually, regardless of the claim amount. You need to indicate the type of injury for each claim using specific injury codes. For example, a medical-only claim should be listed as “6,” while a claim that includes both medical and disability benefits should use the appropriate disability code. Claims must also be marked as open or closed, using “O” for open and “F” for closed/final.
What happens if I submit incomplete or inaccurate information?

Submitting incomplete or inaccurate information can lead to discrepancies in your experience modification factor. NCCI does not verify the accuracy of data submitted by non-affiliates, which means any errors could result in a disclaimer on your modification factor. Therefore, it is crucial to fill out the form completely and accurately to avoid potential issues.
How can I submit the ERM-6 form to NCCI?

You can submit the ERM-6 form via fax or by mail. If you are faxing the form, send it to the Customer Service Center at 561-893-1191. If you have current coverage with NCCI, include a letter of authority from your current carrier. If not, you must include a payment of $75. Remember, all submissions must be made on the approved NCCI ERM-6 form, as no other attachments will be accepted.

Common mistakes

Completing the NCCI ERM-6 form accurately is crucial for obtaining a proper workers' compensation experience rating. However, many individuals encounter common pitfalls that can lead to delays or errors in their submissions. Here are ten mistakes to avoid when filling out the form.

1. Incomplete Information: One of the most frequent mistakes is leaving sections blank. Each column requires specific details, and failing to provide this information can result in processing delays. Ensure all fields are filled out completely, including the risk identification number and effective date of rating.

2. Incorrect Payroll Reporting: Payroll figures must be reported in whole dollars. Submitting amounts like $1,250.50 instead of rounding to the nearest dollar can lead to complications. Always double-check that payroll amounts are rounded properly before submission.

3. Misclassifying Business Activities: Selecting the wrong NCCI classification code can significantly impact your experience rating. Take the time to research and choose the code that accurately reflects your business operations. If uncertain, contacting customer service for clarification is a wise choice.

4. Ignoring Claim Details: Each claim must be reported individually, regardless of the amount. Omitting claims or failing to provide the correct injury type code can result in incomplete data. Remember to note whether claims are open or closed and ensure the appropriate injury codes are assigned.

5. Not Following Submission Guidelines: The instructions provided on the back of the form are there for a reason. Ignoring these guidelines can lead to errors. Make sure to follow the submission process closely, including any requirements for multiple pages or additional documentation.

6. Failing to Provide Contact Information: It’s essential to include accurate contact details, such as phone numbers and email addresses. If NCCI needs to reach you for clarification, having this information readily available can expedite the process.

7. Missing Authorized Signature: The form must be signed by someone with the authority to submit the information. Failing to obtain this signature can result in rejection of the submission. Ensure that the signer’s name and title are clearly printed as well.

8. Neglecting to Review for Accuracy: Before sending the form, take a moment to review all entries for accuracy. Simple typographical errors can lead to significant issues down the line. A thorough review can help catch mistakes before they become problematic.

9. Not Keeping Copies: It’s advisable to keep a copy of the completed ERM-6 form for your records. This can be helpful in case of any disputes or questions regarding the submitted information in the future.

10. Submitting Late: Timeliness is key. Ensure that the form is submitted before the rating effective date. Late submissions may not be processed in time, which can affect your workers' compensation costs and coverage.

By avoiding these common mistakes, individuals can ensure a smoother experience when completing the NCCI ERM-6 form. Taking the time to carefully fill out the form can lead to more accurate ratings and fewer complications down the road.

Documents used along the form

The NCCI ERM-6 form is essential for businesses seeking to obtain their workers' compensation experience rating. Along with this form, several other documents may be necessary to ensure a complete submission. Below is a list of commonly used forms and documents that often accompany the ERM-6.

Loss Runs: This document provides a detailed history of all claims made by the business over a specified period. It includes information on the nature of each claim, the amounts paid, and any outstanding reserves.
Payroll Records: Accurate payroll records are crucial. These documents detail employee earnings and classifications, which are necessary for calculating the experience modification factor.
Classification Codes: A list of NCCI classification codes relevant to the business. These codes categorize the type of work performed and are essential for the rating process.
Letter of Authority: If the business has coverage with a current insurance carrier, a letter of authority on the carrier's letterhead is required. This letter grants permission for the NCCI to access necessary information.
Claims Documentation: This includes any additional paperwork related to specific claims, such as medical reports or settlement agreements, which may provide further context for the claims history.
Payment Information: If there is no current coverage on file with NCCI, a payment of $75 must be submitted. This can be done via credit card, check, or account information.
Contact Information: A document containing the contact details of the person responsible for the submission. This ensures that NCCI can reach out for any clarifications or additional information needed.

Gathering these documents along with the NCCI ERM-6 form will help streamline the rating process. Accurate and complete submissions can lead to a more favorable experience modification factor, ultimately benefiting your business.

Similar forms

ERM-5 Form: Similar to the ERM-6, the ERM-5 form is used for reporting workers' compensation experience rating data. Both forms require details about payroll, claims, and classification codes for accurate rating calculations.
WC-1 Form: The WC-1 form is another document that collects information related to workers' compensation claims. Like the ERM-6, it includes sections for detailing claims, types of injuries, and the status of each claim.
Experience Rating Worksheet: This worksheet serves a similar purpose by summarizing payroll and claims data for experience rating. It shares the need for specific classification codes and the reporting of incurred losses.
Loss Run Report: A Loss Run Report provides a history of claims and losses over a specified period. This report, like the ERM-6, is essential for calculating an employer's experience modification factor.
Claims Summary Report: This report outlines all claims made by a business. It parallels the ERM-6 form by requiring detailed information about each claim, including the nature of injuries and the financial impact.

Dos and Don'ts

When filling out the NCCI ERM-6 form, there are several important practices to follow. Here’s a list of things you should and shouldn't do:

Do fill out all sections completely and accurately.
Do print clearly if you are handwriting the form.
Do round payroll and loss amounts to the nearest whole dollar.
Do include three years of experience, excluding the year prior to the effective date.
Do indicate whether claims are open or closed using “O” or “F”.
Do provide the correct NCCI classification codes for your business.
Do include a letter of authority from the current carrier if applicable.
Don't submit loss runs or worksheets instead of the approved ERM-6 form.
Don't leave any fields blank unless instructed to do so.
Don't submit claims without specifying the injury type code.

Following these guidelines will help ensure that your submission is processed smoothly and accurately.

Misconceptions

There are several misconceptions surrounding the NCCI ERM-6 form that can lead to confusion for those completing it. Understanding these misconceptions can help ensure accurate submissions and a smoother experience rating process.

Misconception 1: The ERM-6 form can include data from the year immediately prior to the effective date of the rating.

This is not true. The form only allows for the inclusion of three years of experience, excluding the year immediately prior to the effective date of the rating. This means that if your rating effective date is April 4, 2024, you cannot include data from the period of April 4, 2023, to April 4, 2024.

Misconception 2: All payroll amounts can be submitted in any format.

In reality, payroll amounts must be rounded to the nearest whole dollar. Submitting amounts in cents or any other format will lead to inaccuracies and potential delays in processing your form.

Misconception 3: Claims do not need to be reported individually if they are below a certain amount.

This is incorrect. Each claim must be reported individually, regardless of the claim amount. This includes claims that may seem minor or small, as they still contribute to the overall experience rating.

Misconception 4: The ERM-6 form can be submitted with additional documents or attachments.

This misconception can cause significant issues. The NCCI requires that all information be submitted solely on the approved ERM-6 form. No additional documents, such as loss runs or spreadsheets, will be accepted.

Key takeaways

Here are some key takeaways for filling out and using the NCCI ERM-6 form:

Complete Accuracy: Fill out the form completely and accurately. This ensures that the information submitted is reliable.
Payroll Rounding: Round payroll and loss amounts to the nearest whole dollar. This is crucial for compliance.
Three-Year Limit: Include data for a total of three years, excluding the year immediately prior to the effective date of the rating.
Injury Codes: Use the correct injury type codes for each claim. Each claim should have its own code.
Open or Closed Claims: Clearly indicate whether claims are open or closed by using "O" for open and "F" for closed.
Submission Format: Only submit the approved NCCI ERM-6 form. Other documents or formats, like Excel spreadsheets, are not accepted.
Authorized Signature: Ensure that the form is signed by someone with the authority to execute the agreement on behalf of the self-insured entity.

Following these guidelines will help streamline the process and ensure a smoother experience with the NCCI ERM-6 form.

Fill in a Valid Ncci Erm 6 Template

Ncci Erm 6 Example

File Breakdown

Guide to Using Ncci Erm 6

Get Answers on Ncci Erm 6

What is the purpose of the NCCI ERM-6 form?

How should I fill out the payroll and losses on the ERM-6 form?

What types of claims need to be reported on the ERM-6 form?