Expense Loss Cost Multiplier Worksheet For Group Sel-Insurance Fund {LIBC-352}

DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS' COMPENSATION EXPENSE LOSS COST MULTIPLIER WORKSHEET FOR GROUP SELF-INSURANCE FUND DEVIATING FROM RATING ORGANIZATION LOSS COSTS MULTIPLIER CALCULATION WORKSHEET AND INSTRUCTIONS Name of fund: Address: City/Town: Insurer code (XXXX): Fund officer responsible for this filing: Title: Telephone: Email address: Fund Year the multiplier calculated in this worksheet covers: From MM State: ZIP: Firm: Ext: Fax: DD YYYY To MM DD YYYY INSTRUCTIONS The following worksheet provides specific parameters for filing an expense loss cost multiplier and an overall contribution amount in compliance with 34 Pa. Code § 125.135 for the upcoming fund year. This worksheet is for use by fund, DEVIATING FROM RATING ORGANIZATION LOSS COSTS. Nothing in the worksheet, these instructions or actuarial guidelines should be construed as placing an upper limit on the degree of additional conservatism that is determined necessary in creating and maintaining adequate surplus for the support of the fund's inherent asset and liability risks. This worksheet and all supporting material must be received by the Bureau of Workers' Compensation no later than 45 days prior to the beginning of the upcoming fund year. Do not deviate from the instructions for each line of the worksheet. The worksheet assumes that no other rate change has been/is being filed for the upcoming fund year, and that fund membership for the upcoming year is relatively known. Please contact the Self-Insurance Division, Bureau of Workers' Compensation, 1171 S. Cameron St., Harrisburg, PA 17104-2501, 717.783.4476, if either of these assumptions is not valid for the fund. The worksheet exhibits should be uploaded as an EXCEL document. Please note that once the bureau approves the loss cost or loss cost multiplier for the upcoming year, the fund must complete and file an ANNUAL CONTRIBUTION WORKSHEET (LIBC-350) on each member. LIBC-352 REV 09-13 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com LOSS COST MULTIPLIER CALCULATION WORKSHEET FOR GROUP DEVIATING FROM RATING ORGANIZATION LOSS COSTS A. MEDICAL AND INDEMNITY LOSSES A. · An actuarial rate analysis (following bureau guidelines for such reports) including an exhibit showing the deviation of the projected loss based upon the fund's projected trended payroll (or other basis of contributions) must be submitted with the form. Box A must be at least as great as such a report's loss estimate (for the upcoming loss year) which the report clearly states is at 75 percent or higher confidence. Such an actuarial estimate may be discounted for a conservative rate of interest to be earned on the upcoming loss year's loss reserve. · The actuarial estimate MUST NOT include any allowance for income from (nor any transfer of) earlier fund years' surplus. · The projection reported in Box A must include medical and indemnity losses only (i.e., net of expenses). If an Allocated Adjustment Expense (ALAE) is present in the "loss" projection developed by the actuary, an estimate of such ALAE must be subtracted before the "loss" projection is placed in Box A. An exhibit of the derivation of any expense estimate being removed from the "loss" projection would then need to be included in this form. Expense estimates within the Expense Exhibits should include both allocated and unallocated expenses. B. ADJUSTED PROJECTION EXCESS INSURANCE PREMIUM NET or GROSS OF EXCESS LOSSES (in dollars) B. · Attach an exhibit or other information explaining amount of estimated excess insurance premium; e.g., a written premium quote. · Is BOX B NET of excess losses (in which case BOX A MUST be an UNLIMITED estimate in that it includes gross loss covered by excess insurance or is BOX B GROSS of excess losses (in which case BOX A would be expected to be an estimate LIMITED by the retention level of excess insurance)? Answer NET GROSS · The premium must also be entered in Part I, Line A of the attached EXPENSE EXHIBIT. C. ADJUSTED PROJECTED VARIABLE EXPENSE (in dollars) C. · Complete the attached EXPENSE EXHIBIT form. The ADJUSTED PROJECTED VARIABLE EXPENSE is taken from Part 1, Line D of that form. D. ADJUSTED PROJECTED FIXED EXPENSE (in dollars) D. · The ADJUSTED PROJECTED FIXED EXPENSE is taken from Part 2, Line B of the EXPENSE EXHIBIT form. E. CONSERVATIVE ESTIMATE OF SURPLUS OR DEFICITS FROM THE CURRENT AND PREVIOUS LOSS YEARS E. · Create an exhibit showing for each loss year a conservative and reasonable estimate of surplus (after discounting losses) for the loss year (with ultimate losses derived from loss data having a valuation date within the last 6 months). If no such analysis has been created for the current loss year, the exhibit will be limited to only prior years. Each surplus should be net of any dividends already approved. · If the sum of such surpluses is negative, meaning a deficit exists, then enter that negative sum into BOX E and submit the exhibit with this form. · If the sum of such surpluses is positive or zero, you may enter 0 into BOX E and submit the exhibit with this form. · If the sum of such surpluses is positive, you may enter the positive amount in BOX E and submit the exhibit with an extra line which shows a selected transfer from surplus by loss year within the following constraints: LIBC-352 REV 09-13 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com EXPENSE LOSS COSTS MULTIPLIER WORKSHEET FOR GROUP SELF-INSURANCE FUND DEVIATING FROM RATING ORGANIZATION LOSS COSTS EXPENSE EXHIBITS AND INSTRUCTIONS FOR COMPLETING BOXES C AND D OF THE WORKSHEET INSTRUCTIONS The following exhibits are used to calculate a group self-insurance fund's projected annual adjusted variable expenses and adjusted fixed expenses for inclusion in the submission of its LOSS COST MULTIPLIER WORKSHEET (LIBC-352). THESE EXHIBITS ARE FOR USE BY FUNDS DEVIATING FROM RATING ORGANIZATION LOSS COSTS. · The fund must make a complete and realistic determination of all its projected costs of operation for the upcoming fund year including all allocated and unallocated loss adjustment expenses and all other expenses not included as a component in the standard contribution. · The fund's administrator should consider adding margins to the projected expenses over and above the best estimate as a source of risk stabilization funding in order to avoid the possibility of deficits. Any unused expense margin would be a source of future surplus. · The projected expenses should be sorted on the attache