Subject 120-2-36 WORKERS' COMPENSATION INSURANCE STATISTICAL AGENT - FORMS AND RATING PLANS

Rule 120-2-36-.06 Insurers Required to Provide Statistics, Data and Information to Statistical Agent and Insured

As a condition to continuing to transact insurance in the State of Georgia, every Insurer authorized to transact Worker's Compensation insurance shall provide to the authorized statistical agent worker's compensation data, statistics including loss ratios and all other relevant information. The foregoing shall be submitted in such a manner (including statistical plan and data collection procedures) as is required by the current statistical plan filed with and approved by the Commissioner by that authorized statistical agent.

(2)

The Insurer shall verify with the Insured, the data to be submitted to the Statistical Agent who shall determine the experience modification factor. Verification of such data shall be accomplished in accordance with this regulation:

(a)

The Insurer shall provide the Insured with a copy of the statistical data being submitted to the Statistical Agent. The statistical data shall be presented in a legible and understandable format. Technical terms shall be avoided wherever possible. It shall be permissible for the insurer to provide the unit statistical report, by whatever name called, in lieu of an independently created form, provided the unit statistical report is accompanied by a legible and understandable explanation of its format.

(b)

The disclosure statement contained in Form GID-63 attached hereto and incorporated herein, or one substantially the same, shall be attached to the statistical data provided to the Insured.

1.

The disclosure shall provide a statement in bold face type, to be signed by an authorized representative of the Insured, that the statistical data has been reviewed and is accurate, and a representative of the Insurer has explained to the Insured's representative that the statistical data may affect the Insured's premium for Georgia Workers' Compensation insurance.

2.

The disclosure shall indicate that the statistical data will be deemed accurate if the disclosure is not returned to the address provided by the Insurer within 30 days from the date mailed.

(i)

The Insurer shall deliver the statistical data and disclosure in person or by depositing the information in the United States mail to be dispatched by at least first-class mail to the last address of record of the Insured, and receiving the receipt provided by the United States Postal Service or such other evidence of mailing as prescribed or accepted by the United States Postal Service.

(ii)	Statistical data that is deemed to be accurate will not in any way affect the right of the Insured to appeal to the Georgia Worker's Compensation Appeals Board.

3.

The disclosure shall also provide a statement for an authorized representative of the Insured to dispute the accuracy of the data. The statement shall direct the Insured to clearly identify any discrepancies. The disputed data shall be furnished to the Insurer by the return date indicated on the disclosure statement.

(i)	If the Insurer confirms the accuracy of the information provided by the Insured, the Insurer shall correct their records and proceed to furnish the amended data to the Statistical Agent.

(ii)

If the Insurer does not agree with the data provided by the Insured, the Insurer shall submit the Insurer's data to the Statistical Agent.

(I)	The Insurer shall notify the risk within 60 days of the original mail date that the experience modification factor will be promulgated from the information provided by the Insurer.

(II)	The Insured shall be instructed, in detail, of their right to appeal to the Georgia Workers' Compensation Appeals Board.

(III)

The Insurer's failure to respond to the Insured in the time prescribed shall be deemed an acknowledgement that the insured's records are accurate, and amendments are to be made before reporting the statistical data to the Statistical Agent.

(c)	Verification of data shall not be mandatory for insured who are not eligible for experience rating, however, the data and explanation shall be furnished to insureds upon request.

Rule 120-2-36-.07 Maintenance of Records by Authorized Statistical Agent(s)

Rule 120-2-36-.08 Filing of Rating Plans, Rating Systems and Underwriting Rules

Rule 120-2-36-.09 Standard Workers' Compensation Insurance Policy

Rule 120-2-36-.10 Filing of Standard Workers' Compensation Insurance Policy and Other Forms

Rule 120-2-36-.11 Filing of Annual Statistical Data

(1)

As a condition to continuing to transact insurance in the State of Georgia, every insurer authorized to transact workers' compensation insurance shall file with the Insurance Commissioner, before March 1, of each year, an exhibit of its premium losses, expenses and investment income as of December 31 of the previous calendar year. Each insurer shall provide all information and data necessary to factually complete each blank space in such exhibit unless it is unequivocally clear that such blank has no application to the insurer. Each insurer shall supply true and correct answers to any and all interrogatories on the exhibit and shall supply, insert or attach to such exhibit all data, information and answers required or suggested by any note, footnote or lack of space in such forms. After supplying all answers, information or data necessary or proper to complete such form in every detail, each insurer shall cause its officers or employees specified in such exhibit to certify that the information is true and accurate in every detail.

(2)	Any "designated carrier" for the workers' compensation insurance plan shall provide a separate report for their involuntary business.

Rule 120-2-36-.12 Severability

If any provision of this Regulation, or the application thereof, to any person or circumstance is held invalid by a court of competent jurisdiction, the remainder of the Regulation or the applicability of such provisions to other persons or circumstances shall not be affected.

IMPORTANT

DISCLOSURE STATEMENT

_________________________

Date of Mailing

TO: Policy Holder Carrier's Return Address

Attached, as required by Georgia Law, is a copy of the loss experience to be used in experience rating your workers compensation policy. The experience rating can cause your premiums to increase or decrease depending on the frequency end severity of losses.

In accordance with the O.C.G.A. Section 34-9-136, please review the attached statement, sign below and return this form to our office. If you do not sign and return this form within 30 days from the mailing date, the date will be deemed correct for the purpose of calculating your experience rating modification factor end final premium. Your failure to respond shall not affect nor waive any of your rights to a future appeal.

If you find an error in the attached material, please contact our office immediately at the indicated address:

SIGN THE APPLICABLE STATEMENT BELOW

AND RETURN REQUIRED STATEMENT

I have reviewed the attached payroll and claims information and find it to be accurate. An insurance company representative has explained that this information may affect the premium charged for Workers' Compensation Insurance Coverage for my business.

___________________________________________

SIGNATURE & TITLE

(Authorized Representative of the Employer)

I have reviewed the attached payroll and claims information. According to my records, the information is inaccurate. I have attached a copy of my records which I believe to be correct and a statement explaining the differences. I understand that if you, the insurance company, do not respond to me within 60 days of the date on your statement, you are agreeing with me that my records are correct and you will change your records accordingly.

___________________________________________

SIGNATURE & TITLE

(Authorized Representative of the Employer)

(NOTE: Return by _______________)

Date

IF YOU ARE AN INDIVIDUAL WITH A DISABILITY AND WISH TO ACQUIRE THIS PUBLICATION IN AN ALTERNATIVE FORMAT, PLEASE CONTACT THE ADA COORDINATOR, PROPERTY & CASUALTY DIVISION, OFFICE OF COMMISSIONER OF INSURANCE, NO 2 MARTIN LUTHER KING, JR. DRIVE, ATLANTA, GEORGIA 30334 (404) 656-2056, TDD # (404) 656-4031

Subject 120-2-36 WORKERS' COMPENSATION INSURANCE STATISTICAL AGENT - FORMS AND RATING PLANS

Rule 120-2-36-.01 Statutory Authority

Rule 120-2-36-.02 Purpose

Rule 120-2-36-.03 Applicability

Rule 120-2-36-.04 Definitions

Rule 120-2-36-.05 Statistical Agent - Designation and Duties