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Run: Experience Modification Factor Verification Worksheet

Verify the NCCI experience modification factor, payroll, classification codes, and loss data used on a workers' compensation policy before disputes or renewa...

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Worksheet Overview

Verification Date (required)

Verified By (required)

Verification Purpose (required)

Policy Number (required)

Policy Effective Period (required)

Enter the policy term being reviewed, such as 01/01/2025 to 01/01/2026.

Employer and Policy Details

Insured Name (required)

State or Jurisdiction (required)

NCCI Experience Modification Factor (required)

Enter the experience modifier as shown on the rating worksheet or carrier notice.

Modifier Effective Date (required)

Source of Modifier (required)

Payroll and Classification Summary

Classification Codes Reviewed (required)

Total Estimated or Audited Payroll (required)

Enter the total payroll amount reviewed for the policy term.

Payroll Basis (required)

Payroll Discrepancy Identified? (required)

Payroll Discrepancy Notes

Describe the variance, source documents reviewed, and any follow-up needed.

Loss and Claim Data Review

Number of Claims Reviewed (required)

Loss Run Source (required)

Loss Data Matches Source Documents? (required)

Loss Discrepancy Summary

Summarize missing claims, incorrect reserves, duplicate entries, or other variances.

Verification Outcome

Verification Result (required)

Exceptions Summary

Describe the specific items that do not match and what documentation is needed to resolve them.

Follow-up Owner

Next Review Date

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