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
Rule 120-2-36-.06 Insurers Required to Provide Statistics, Data and Information to Statistical Agent and Insured
| (1) | 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:
|
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