Experience Modification Factor Verification Worksheet

Worksheet for verifying the NCCI experience modification factor and the underlying payroll, classification, and loss data on a workers' compensation policy.

Worksheet Overview

• Verification Date
• Verified By
• Verification Purpose
• Policy Number
• Policy Effective Period
  Enter the policy term being reviewed, such as 01/01/2025 to 01/01/2026.

Employer and Policy Details

• Insured Name
• State or Jurisdiction
• NCCI Experience Modification Factor
  Enter the experience modifier as shown on the rating worksheet or carrier notice.
• Modifier Effective Date
• Source of Modifier

Payroll and Classification Summary

• Classification Codes Reviewed
• Total Estimated or Audited Payroll
  Enter the total payroll amount reviewed for the policy term.
• Payroll Basis
• Payroll Discrepancy Identified?
• Payroll Discrepancy Notes
  Describe the variance, source documents reviewed, and any follow-up needed.

Loss and Claim Data Review

• Number of Claims Reviewed
• Loss Run Source
• Loss Data Matches Source Documents?
• Loss Discrepancy Summary
  Summarize missing claims, incorrect reserves, duplicate entries, or other variances.

Verification Outcome

• Verification Result
• Exceptions Summary
  Describe the specific items that do not match and what documentation is needed to resolve them.
• Follow-up Owner
• Next Review Date