New York Workers' Compensation User Guide - … · It is our intent to write Workers’...

New York Workers’ Compensation

User Guide

Merchants Mutual Insurance Company Merchants Preferred Insurance Company

WORKERS’ COMPENSATION NEW YORK (31)

TABLE OF CONTENTS

General Eligibility

Agents Binding Authority

Classes Eligible for Binding

Contractors

Professional and Clerical

Mercantile and Light Service

Miscellaneous Classes

Dividend Plan


WORKERS’ COMPENSATION GENERAL ELIGIBILITY

NEW YORK (31)

It is our intent to write Workers’ Compensation coverage in conjunction with our other lines of business. Agents are encouraged to bind and submit coverage on selected mercantile, service, office and contracting risks per the eligible class listing in this manual. Other risks require approval prior to binding. Please refer to the section on Binding Authority as well as the Eligible Class Section of this manual for more complete information. Merchants will generally not provide Workers’ Compensation coverage on

▪ Manufacturing Risks

▪ Carpentry and Related Trades such as Roofing

▪ Cabinet Installation

▪ Ceiling and Wall Installation

▪ Drywall Installation

▪ Fence Installation

▪ Siding Installation

▪ Sheet Metal Work (except in conjunction with heating and cooling operations)


WORKERS’ COMPENSATION AGENTS BINDING AUTHORITY

MA, NH, NJ, NY, PA, VT

When written in conjunction with an eligible BOP, MAP Contractors or Commercial Package Policy, you are granted binding authority for the classes listed in the “Classes Eligible for Binding” section of this manual. In addition, the following company specific eligibility requirements are applicable.

CATEGORY MUTUAL PREFERRED

Loss Ratio 3 year loss ratio under 50% supported with currently valued hard copy loss runs or signed verification of loss statement.

3 year loss ratio under 35% supported with currently valued hard copy loss runs or signed verification of loss statement.

Ownership or Management Experience

Three years ownership or management experience in the industry or trade.

The applicant must have been in business for three years as owner of this business.

Experience Modification Experience modification less than or equal to 1.05

No binding authority for debit mods (must be referred to Company)

Minimum Premium: State Bureau imposed minimum premiums per class or policy still apply

No Restriction $500

Coverage for Owners, Officers, Partners, and Family Members

Ownership, officers, partners and family members may not represent more than 25% of the total premium basis. Do not include payroll for excluded individuals in the calculation

Persons who drive in the course of employment

Favorable driver MVR profile per current company underwriting guidelines. Please refer to company commercial automobile guidelines in the agents’ section of “My Merchants” at www.merchantsgroup.com

Additional Class Requirements See included list.

Any risk that does not meet the above guidelines cannot be bound without prior approval from the Company. Classes not on the attached listing may be submitted on an inquiry basis when associated with an eligible BOP, MAP Contractors or Commercial Package Policy.


WORKERS’ COMPENSATION CLASSES ELIGIBLE FOR BINDING

NEW YORK (31)

CONTRACTORS

0042 ▪ Landscape Gardening & Drivers

5183 ▪ Carrier System Installation or Repair & Drivers▪ Plumbing NOC and Drivers

5190 ▪ Electronic Wiring – Within Buildings

5191 ▪ Computer Device Installation Inspection Service or Repair▪ Office Machine Installation or Repair

5192 ▪ Vending Machines - Installation, Service or Repair- and Route Sales, Route Supervisors

and Drivers

5221 ▪ Concrete or Cement Work – Floors, Driveways, Yards or Sidewalks & Drivers▪ Paving or Repaving Floors, Driveways, Yards or Sidewalks + D

5348 ▪ Marble or Stone Setting – Inside▪ Mosaic, Stone, Terrazzo or Tile Work – Inside▪ Stone or Marble Setting – Inside

5429 ▪ Furniture or Fixtures Installation in Offices or Stores NOC

5462 ▪ Glazier - Away From Shop and Drivers

5474 ▪ Painting or Decorating NOC and Drivers

5536 ▪ Air Conditioning and Heating Duct Work – Shop and Outside and Drivers

5538 ▪ Wall Covering or Metal Ceiling Installation and Shop, Drivers

8601 ▪ Architect or Engineer – Consulting▪ Surveyor

9519 ▪ Household Appliances – Electrical Installation, Service or Repair and Drivers

9521 ▪ Carpet Installation▪ House Furnishings Installation NOC

9522 ▪ Furniture Upholstering▪ Upholstering



NEW YORK (31)

PROFESSIONAL AND CLERICAL

4692 ▪ Dental Laboratory

8742 ▪ Claim Adjusters or Special Agency – Insurance Company ▪ Salespersons, Collectors or Messengers - Outside ▪ Real Estate Agency – Outside Employees and Collectors

8800 ▪ Addressing Company ▪ Mailing Company

8809 ▪ Executive Officers NOC not Foremen, Workers or Salespersons

8810 ▪ Clerical Office Employees NOC ▪ Computer Systems, Designers or Programmers: Exclusively Office ▪ Drafting Employees

8820 ▪ Attorney – All Employees and Clerical, Messengers, Drivers ▪ Law Office – All Employees and Clerical, Messengers, Drivers

8831 ▪ Hospital – Veterinary – and Drivers

8832 ▪ Dentist and Clerical ▪ Physician and Clerical

9586

▪ Barber Shop ▪ Beauty Shop ▪ Day Spa ▪ Nail Salon

9620 ▪ Funeral Director and Drivers ▪ Undertaker and Drivers



NEW YORK (31)

MERCANTILE AND LIGHT SERVICE

0035 ▪ Florist & Drivers – Cultivating or Gardening

2003 ▪ Bakery & Route Salespersons, Route Supervisors, Drivers

2503 ▪ Tailor Shop

2590 ▪ Dry Cleaning or Laundry – Retail & Route Salespersons

2591 ▪ Dry Cleaning or Laundry – Commercial & Route Salespersons and Drivers

2593 ▪ Upholstery, Carpet or Rug Cleaning – Shop or Outside & Route Salespersons, Drivers

4299 ▪ Printing

4310 ▪ Stores: Greeting Card Dealer – Wholesale

4361 ▪ Photographer – All Employees & Drivers ▪ Portrait Studio – All Employees & D

7390 ▪ Beer or Ale Dealer – Wholesale & Drivers

7998 ▪ Stores: Hardware Store Retail

8006

▪ Store: Coffee, Tea, Spice Store – Retail ▪ Store: Dairy Products – Retail ▪ Store: Delicatessen – Retail ▪ Store: Frozen or Frosted Food – Retail ▪ Store: Fruit or Vegetable Store – Retail ▪ Store: Grocery Store – Retail

8008 ▪ Store: Clothing, Wearing Apparel or Dry Goods Store – Retail ▪ Store: Dry Goods Store-Retail ▪ Store: Shoe Store-Retail

8013 ▪ Store: Jewelry – Wholesale or Retail

8016 ▪ Photocopy Shops – All Employees & Clerical & Salesperson

8017

▪ Dry Cleaning or Laundry – Collecting or Distributing Store ▪ Laundry or Dry Cleaning Store – Self Service Type ▪ Stores: Drug or Cigar Store – No Service of Food ▪ Stores: Retail Store NOC – No Service of Food

8018 ▪ Wholesale Stores NOC

8021 ▪ Store: Fish Store – Wholesale

8031 ▪ Store: Fish Store – Retail ▪ Meat Store: Retail ▪ Poultry Store – Retail

8032 ▪ Stores: Dry Goods Store – Wholesale ▪ Stores: Shoe Store - Wholesale



NEW YORK (31)

MERCANTILE AND LIGHT SERVICE (CONT’D)

8034

▪ Stores: Coffee, Tea or Spice Store – Wholesale ▪ Stores: Dairy Products Store – Wholesale ▪ Frozen or Frosted Food Store – Wholesale ▪ Store: Grocery Store – Wholesale

8043 ▪ Stores: Drug or Cigar – Store – Including Service of Food – Not Restaurant ▪ Stores: Retail Store NOC Including Service of Food Not Restaurant ▪ Bagel Shops - Retail

8044 ▪ Stores: Furniture Store Wholesale or Retail & Inside Salespersons, Drivers

8046 ▪ Stores: Automobile Accessories Store – Retail NOC & Drivers

8047 ▪ Stores: Drug Store – Wholesale

8048 ▪ Stores: Fruit or Vegetable Store – Wholesale

8111 ▪ Plumbers' Supplies Dealer & Drivers NPD

8391

▪ Automobile Body Repair Shop – All Operations and Drivers ▪ Automobile Gasoline Station – Full or Full and Self Service and Drivers ▪ Automobile Laundry and Drivers ▪ Automobile Repair Shop – All Operations and Drivers ▪ Automobile Sales or Service Agency – All Operations and Drivers ▪ Automobile Service Station – Full or Full and Self Service and Drivers ▪ Automobile Tire Dealers and Drivers

8392

▪ Automobile Parking Lot and Drivers ▪ Automobile Parking Station and Drivers ▪ Automobile Valet Parking Service and Drivers ▪ Parking Lot – Automobile and Drivers ▪ Storage Garage Automobile

9060 ▪ Club – Country, Golf, Fishing or Yacht and Clerical (Used for Public Golf Courses)

9071 ▪ Catering ▪ Restaurant: Full Service

9072 ▪ Doughnut Shop ▪ Restaurant: Fast Food and Drivers

9539 ▪ Decorating and Drivers

9585 ▪ Shoe Repair Shop



NEW YORK (31)

MISCELLANEOUS CLASSES

0908 ▪ Domestic Workers – Inside Occasional

0909 ▪ Domestic Workers – Outside – Occasional Including Occasional Private Chauffeurs

0912 ▪ Domestic Workers – Outside – Including Private Chauffeurs

7380 ▪ Drivers & Helpers NOC – Commercial

Merchants Mutual Insurance Company

WORKERS’ COMPENSATION DIVIDEND PLAN

NEW YORK (31)


Effective 01/01/2010 the following dividend plan will be in effect for Merchants Mutual Insurance Company:

▪ The plan is designed to evaluate losses and calculate dividends twelve months after policy expiration.

To qualify for participation in our dividend program, a risk must meet the following criteria:

▪ The minimum estimated premium at inception and at final audit must be $10,000 or more, excluding fees and assessments.

▪ Loss ratio of 45% or less. ▪ Both the Insured and the Company must agree to participation in the plan. The agreement is shown by the

attachment of endorsement MU 8141 (06/05). ▪ Policies canceled mid-term are not eligible, regardless of the premium.

The dividend table is as follows:

Premium Groups (000’s)

Loss Ratio 10-15 15-25 25-50 50-99 100+

0.0% 18.0% 20.0% 22.0% 24.0% 25.0%

>0-5.0% 16.2% 18.0% 19.8% 21.6% 22.5%

>5-10.0% 14.4% 16.0% 17.6% 19.2% 20.0%

>10-15.0% 12.6% 14.0% 15.4% 16.8% 17.5%

>15-20.0% 10.8% 12.0% 13.2% 14.4% 15.0%

>20-25.0% 9.0% 10.0% 11.0% 12.0% 12.5%

>25-30.0% 7.2% 8.0% 8.8% 9.6% 10.0%

>30-35.0% 5.4% 6.0% 6.6% 7.2% 7.5%

>35-40.0% 3.6% 4.0% 4.4% 4.8% 5.0%

>40-45.0% 1.8% 2.0% 2.2% 2.4% 2.5%

>45% 0.0% 0.0% 0.0% 0.0% 0.0%


WORKERS’ COMPENSATION RATE PAGES NEW YORK (31)

Loss Cost Multiplier ...................... 1.316 Minimum Premium Multiplier ................... 110 Maximum Minimum Premium .................. 875

Refer to Footnotes Pages for additional information Effective Date 10/01/18

CLASS NO LOSS COST RATE MINIMUM PREMIUM

0005 3.06 4.03 643

0006 3.48 4.58 704

0007 2.41 3.17 549

0031 2.88 3.79 617

0034 3.76 4.95 745

0035 2.90 3.82 620

0042 6.24 8.21 875

0050 5.14 6.76 875

0106 9.57 12.59 875

0251 18.05 23.75 875

0771 N 6.75 8.88 875

0908 PC 155.29 204.36 254

0909 PC 211.66 278.54 329

0912 PC 832.31 1095.32 1145

0913 PC 338.22 445.10 495

0917 5.39 7.09 875

1170 4.53 5.96 856

1320 6.03 7.94 875

1430 4.24 5.58 814

1438 9.03 11.88 875

1439 6.13 8.07 875

1452 7.63 10.04 875

1463 7.26 9.55 875

1470 12.25 16.12 875

1624 4.82 6.34 875

1701 6.05 7.96 875

1710 6.73 8.86 875

1741 6.42 8.45 875

1747 22.27 29.31 875

1748 10.39 13.67 875

1809 13.35 17.57 875

1810 10.04 13.21 875






1853 5.32 7.00 875

1860 13.68 18.00 875

1924 6.10 8.03 875

1925 8.64 11.37 875

2001 5.92 7.79 875

2002 5.58 7.34 875

2003 6.28 8.26 875

2014 5.01 6.59 875

2021 4.12 5.42 796

2039 6.48 8.53 875

2041 5.46 7.19 875

2065 4.39 5.78 836

2070 6.44 8.48 875

2081 12.76 16.79 875

2089 10.62 13.98 875

2095 8.47 11.15 875

2101 4.74 6.24 875

2105 7.84 10.32 875

2111 3.46 4.55 701

2112 9.75 12.83 875

2114 6.66 8.76 875

2121 4.55 5.99 859

2143 4.78 6.29 875

2150 12.40 16.32 875

2157 11.65 15.33 875

2172 3.71 4.88 737

2288 8.94 11.77 875

2302 3.08 4.05 646

2362 2.36 3.11 542

2380 10.26 13.50 875

2387 4.21 5.54 809

2388 3.28 4.32 675






2402 2.74 3.61 597

2413 4.67 6.15 875

2416 2.56 3.37 571

2417 3.73 4.91 740

2501 0.93 1.22 334

2503 1.13 1.49 364

2534 5.60 7.37 875

2553 2.99 3.93 632

2570 5.52 7.26 875

2571 3.90 5.13 764

2576 4.15 5.46 801

2578 3.35 4.41 685

2590 3.03 3.99 639

2591 5.55 7.30 875

2593 6.45 8.49 875

2594 7.13 9.38 875

2600 7.36 9.69 875

2623 4.46 5.87 846

2640 16.66 21.92 875

2660 2.97 3.91 630

2670 3.53 4.65 712

2683 5.65 7.44 875

2688 1.71 2.25 448

2689 1.08 1.42 356

2702 16.47 21.67 875

2710 7.45 9.80 875

2714 9.76 12.84 875

2731 5.64 7.42 875

2737 6.32 8.32 875

2759 13.27 17.46 875

2790 2.02 2.66 493

2802 7.83 10.30 875






2816 4.08 5.37 791

2817 4.66 6.13 874

2818 5.00 6.58 875

2835 3.10 4.08 649

2841 4.70 6.19 875

2881 3.35 4.41 685

2883 4.17 5.49 804

2913 5.01 6.59 875

2916 4.70 6.19 875

2923 2.12 2.79 507

2942 T 3.01 3.96 636

3004 6.07 7.99 875

3018 10.16 13.37 875

3022 9.46 12.45 875

3027 3.26 4.29 672

3028 14.22 18.71 875

3030 11.43 15.04 875

3040 11.20 14.74 875

3041 6.41 8.44 875

3042 4.96 6.53 875

3060 14.36 18.90 875

3064 7.93 10.44 875

3066 3.81 5.01 751

3067 3.74 4.92 741

3076 3.62 4.76 724

3081 7.17 9.44 875

3085 6.79 8.94 875

3110 14.42 18.98 875

3111 6.39 8.41 875

3113 2.20 2.90 519

3114 3.18 4.18 660

3118 2.84 3.74 611






3122 5.30 6.97 875

3126 16.00 21.06 875

3129 4.09 5.38 792

3132 2.52 3.32 565

3145 2.51 3.30 563

3146 2.00 2.63 489

3169 4.80 6.32 875

3179 2.77 3.65 602

3188 3.68 4.84 732

3190 3.37 4.43 687

3191 4.74 6.24 875

3200 3.44 4.53 698

3220 3.26 4.29 672

3227 32.33 42.55 875

3241 5.51 7.25 875

3257 3.87 5.09 760

3270 2.69 3.54 589

3307 4.36 5.74 831

3315 10.33 13.59 875

3336 2.58 3.40 574

3365 9.62 12.66 875

3372 3.29 4.33 676

3381 2.51 3.30 563

3383 0.62 0.82 290

3384 0.31 0.41 245

3385 1.20 1.58 374

3400 8.92 11.74 875

3507 3.63 4.78 726

3515 3.72 4.90 739

3548 2.74 3.61 597

3559 3.45 4.54 699

3561 2.95 3.88 627






3574 0.84 1.11 322

3581 2.05 2.70 497

3612 3.13 4.12 653

3620 5.97 7.86 875

3629 1.96 2.58 484

3632 3.84 5.05 756

3634 2.23 2.93 522

3635 3.15 4.15 657

3638 3.76 4.95 745

3642 2.49 3.28 561

3643 2.81 3.70 607

3647 5.53 7.28 875

3648 2.34 3.08 539

3681 1.60 2.11 432

3685 1.60 2.11 432

3686 2.24 2.95 525

3724 5.48 7.21 875

3726 10.98 14.45 875

3737 5.29 6.96 875

3807 6.20 8.16 875

3808 4.51 5.94 853

3821 9.74 12.82 875

3823 5.95 7.83 875

3824 6.30 8.29 875

3826 1.92 2.53 478

3827 6.43 8.46 875

3830 3.10 4.08 649

3832 3.58 4.71 718

3865 2.92 3.84 622

3881 (a) - -

4000 6.90 9.08 875

4024 4.70 6.19 875






4034 10.88 14.32 875

4038 3.65 4.80 728

4053 5.70 7.50 875

4061 5.00 6.58 875

4062 6.45 8.49 875

4101 3.71 4.88 737

4111 3.58 4.71 718

4112 2.14 2.82 510

4114 2.96 3.90 629

4130 8.55 11.25 875

4131 4.70 6.19 875

4133 2.52 3.32 565

4150 2.02 2.66 493

4207 1.39 1.83 401

4239 3.50 4.61 707

4240 5.50 7.24 875

4243 4.25 5.59 815

4244 3.00 3.95 635

4250 3.07 4.04 644

4251 3.03 3.99 639

4263 5.56 7.32 875

4273 3.76 4.95 745

4279 4.59 6.04 864

4282 0.51 0.67 274

4298 2.68 3.53 588

4299 2.75 3.62 598

4301 9.03 11.88 875

4304 9.95 13.09 875

4307 3.59 4.72 719

4310 3.33 4.38 682

4312 3.07 4.04 644

4351 2.37 3.12 543






4352 0.79 1.04 314

4360 0.35 0.46 251

4361 0.81 1.07 318

4362 0.58 0.76 284

4410 5.61 7.38 875

4420 13.28 17.48 875

4431 5.47 7.20 875

4432 2.35 3.09 540

4439 T 3.34 4.40 684

4452 3.82 5.03 753

4459 4.35 5.72 829

4470 4.36 5.74 831

4475 2.97 3.91 630

4476 2.25 2.96 526

4479 2.95 3.88 627

4493 5.95 7.83 875

4511 0.76 1.00 310

4557 1.87 2.46 471

4558 4.74 6.24 875

4568 3.45 4.54 699

4583 9.25 12.17 875

4597 3.01 3.96 636

4611 2.37 3.12 543

4628 1.95 2.57 483

4635 6.29 8.28 875

4653 2.78 3.66 603

4665 14.19 18.67 875

4692 1.16 1.53 368

4693 2.51 3.30 563

4710 3.76 4.95 745

4712 2.91 3.83 621

4720 4.83 6.36 875






4751 3.13 4.12 653

4771 N 4.45 5.86 845

4825 0.97 1.28 341

4828 2.10 2.76 504

4829 2.85 3.75 613

4902 4.09 5.38 792

4923 1.58 2.08 429

5000 21.41 28.18 875

5022 20.68 27.21 875

5037 30.74 40.45 875

5040 24.27 31.94 875

5057 17.36 22.85 875

5059 42.31 55.68 875

5069 33.68 44.32 875

5102 13.21 17.38 875

5160 5.28 6.95 875

5183 7.79 10.25 875

5184 8.77 11.54 875

5188 6.90 9.08 875

5190 5.67 7.46 875

5191 1.54 2.03 423

5192 4.36 5.74 831

5193 9.89 13.02 875

5213 19.61 25.81 875

5221 13.05 17.17 875

5222 9.91 13.04 875

5223 9.50 12.50 875

5348 8.82 11.61 875

5402 9.38 12.34 875

5403 15.69 20.65 875

5428 6.29 8.28 875

5429 8.02 10.55 875






5443 10.17 13.38 875

5445 9.65 12.70 875

5462 8.78 11.55 875

5473 26.19 34.47 875

5474 10.47 13.78 875

5479 7.55 9.94 875

5480 12.88 16.95 875

5491 3.34 4.40 684

5506 14.21 18.70 875

5507 7.96 10.48 875

5508 7.15 9.41 875

5536 7.50 9.87 875

5538 8.19 10.78 875

5545 21.84 28.74 875

5547 14.03 18.46 875

5606 4.49 5.91 850

5610 10.09 13.28 875

5645 11.13 14.65 875

5648 19.35 25.46 875

5651 7.48 9.84 875

5701 19.41 25.54 875

5703 31.42 41.35 875

5709 23.02 30.29 875

5951 1.03 1.36 350

5954 5.57 7.33 875

6003 11.71 15.41 875

6005 5.33 7.01 875

6017 3.35 4.41 685

6018 13.44 17.69 875

6045 5.17 6.80 875

6204 8.98 11.82 875

6216 9.71 12.78 875






6217 8.37 11.01 875

6229 5.95 7.83 875

6233 5.93 7.80 875

6235 8.37 11.01 875

6251 15.99 21.04 875

6252 3.68 4.84 732

6260 (a) - -

6306 10.77 14.17 875

6319 7.35 9.67 875

6325 7.60 10.00 875

6400 7.09 9.33 875

6504 4.63 6.09 870

6701 17.40 22.90 875

6801 F 35.58 46.82 875

6811 5.94 7.82 875

6824 F 15.06 19.82 875

6826 F 5.95 7.83 875

6834 5.05 6.65 875

6836 3.75 4.94 743

6843 F 8.56 11.26 875

6854 3.06 4.03 643

6872 F 24.13 31.76 875

6874 F 63.71 83.84 875

6875 F 106.19 139.75 875

6882 5.07 6.67 875

6884 45.93 60.44 875

6885 65.45 86.13 875

7016 6.76 8.90 875

7024 7.52 9.90 875

7038 2.94 3.87 626

7046 2.96 3.90 629

7047 13.37 17.59 875






7050 5.81 7.65 875

7090 3.27 4.30 673

7098 3.28 4.32 675

7099 5.84 7.69 875

7133 5.01 6.59 875

7197 9.56 12.58 875

7201 4.55 5.99 859

7207 5.22 6.87 875

7219 11.50 15.13 875

7231 9.35 12.30 875

7242 24.12 31.74 875

7309 F 5.64 7.42 875

7313 F 2.73 3.59 595

7317 F 28.63 37.68 875

7327 F 30.72 40.43 875

7333 5.41 7.12 875

7335 6.01 7.91 875

7337 10.68 14.05 875

7364 2.08 2.74 501

7366 F 9.80 12.90 875

7367 8.52 11.21 875

7368 8.43 11.09 875

7370 (c) - -

7377 9.26 12.19 875

7380 * 9.43 12.41 875

7390 17.96 23.64 875

7394 4.12 5.42 796

7395 4.59 6.04 864

7398 8.15 10.73 875

7403 6.49 8.54 875

7405 N 1.66 2.18 440

7421 0.82 1.08 319






7422 2.93 3.86 625

7431 N 0.62 0.82 290

7445 N 0.38 0.50 255

7453 N 0.36 0.47 252

7502 2.18 2.87 516

7515 2.19 2.88 517

7520 7.29 9.59 875

7536 8.37 11.01 875

7538 4.32 5.69 826

7539 1.65 2.17 439

7542 6.14 8.08 875

7580 5.77 7.59 875

7590 5.67 7.46 875

7600 7.57 9.96 875

7601 4.92 6.47 875

7610 0.25 0.33 236

7710 4.07 5.36 790

7711 (e) - -

7716 (e) - -

7720 2.50 3.29 562

7723 1.85 2.43 467

7855 5.25 6.91 875

7998 2.85 3.75 613

7999 2.42 3.18 550

8001 3.20 4.21 663

8006 1.83 2.41 465

8008 1.00 1.32 345

8012 1.64 2.16 438

8013 0.41 0.54 259

8016 0.62 0.82 290

8017 1.55 2.04 424

8018 3.87 5.09 760






8021 6.37 8.38 875

8025 1.62 2.13 434

8031 2.85 3.75 613

8032 1.08 1.42 356

8033 3.85 5.07 758

8034 5.69 7.49 875

8039 2.11 2.78 506

8043 1.23 1.62 378

8044 3.68 4.84 732

8046 3.75 4.94 743

8047 1.83 2.41 465

8048 5.71 7.51 875

8068 0.34 0.45 250

8069 0.74 0.97 307

8072 0.97 1.28 341

8090 0.84 1.11 322

8102 8.40 11.05 875

8103 5.70 7.50 875

8105 2.89 3.80 618

8106 6.95 9.15 875

8107 3.82 5.03 753

8111 4.33 5.70 827

8116 2.31 3.04 534

8199 3.50 4.61 707

8209 8.31 10.94 875

8215 6.95 9.15 875

8227 12.43 16.36 875

8232 6.65 8.75 875

8235 5.57 7.33 875

8263 9.75 12.83 875

8264 6.88 9.05 875

8265 10.54 13.87 875






8280 18.30 24.08 875

8288 4.30 5.66 823

8291 8.13 10.70 875

8292 5.08 6.69 875

8293 10.83 14.25 875

8350 9.54 12.55 875

8353 5.87 7.72 875

8381 2.67 3.51 586

8382 2.17 2.86 515

8385 8.95 11.78 875

8391 3.78 4.97 747

8392 3.05 4.01 641

8394 5.66 7.45 875

8500 8.05 10.59 875

8601 0.48 0.63 269

8709 F 28.82 37.93 875

8719 2.61 3.43 577

8720 2.29 3.01 531

8726 F 3.77 4.96 746

8731 2.98 3.92 631

8742 0.31 0.41 245

8745 6.38 8.40 875

8747 0.18 0.24 226

8748 1.32 1.74 391

8751 4.07 5.36 790

8755 0.65 0.86 295

8800 2.05 2.70 497

8802 1.32 1.74 391

8803 0.06 0.08 209

8809 0.22 0.29 232

8810 & 0.14 0.18 220

8820 0.13 0.17 219






8829 3.77 4.96 746

8831 1.38 1.82 400

8832 0.46 0.61 267

8833 @ 1.46 1.92 411

8838 0.54 0.71 278

8840 0.51 0.67 274

8854 4.83 6.36 875

8857 3.04 4.00 640

8864 3.39 4.46 691

8865 3.49 4.59 705

8866 3.04 4.00 640

8868 0.50 0.66 273

8869 0.97 1.28 341

8871 0.23 0.30 233

8901 0.10 0.13 214

9014 5.03 6.62 875

9015 1.87 2.46 471

9016 5.55 7.30 875

9019 3.92 5.16 768

9025 19.97 26.28 875

9026 4.71 6.20 875

9027 PL 13.84 18.21

9028 3.45 4.54 699

9029 5.79 7.62 875

9030 5.73 7.54 875

9040 # 5.04 6.63 875

9044 6.19 8.15 875

9048 § 2.71 3.57 593

9051 4.25 5.59 815

9052 3.47 4.57 703

9055 1.27 1.67 384

9058 4.01 5.28 781






9059 9.56 12.58 875

9060 1.80 2.37 461

9061 2.08 2.74 501

9063 1.10 1.45 360

9065 1.27 1.67 384

9071 2.03 2.67 494

9072 2.35 3.09 540

9074 1.32 1.74 391

9088 10.81 14.23 875

9089 0.46 0.61 267

9093 2.17 2.86 515

9101 3.27 4.30 673

9102 4.23 5.57 813

9149 1.74 2.29 452

9157 4.84 6.37 875

9158 2.08 2.74 501

9159 1.46 1.92 411

9160 1.58 2.08 429

9178 3.70 4.87 736

9179 7.72 10.16 875

9180 2.80 3.68 605

9182 1.64 2.16 438

9186 7.92 10.42 875

9220 8.83 11.62 875

9402 6.52 8.58 875

9403 13.32 17.53 875

9410 8.31 10.94 875

9501 2.06 2.71 498

9505 5.55 7.30 875

9519 4.75 6.25 875

9521 5.18 6.82 875

9522 1.85 2.43 467






9526 13.21 17.38 875

9527 32.89 43.28 875

9534 10.88 14.32 875

9539 11.51 15.15 875

9545 15.34 20.19 875

9549 3.50 4.61 707

9552 13.66 17.98 875

9553 7.28 9.58 875

9585 1.05 1.38 352

9586 0.63 0.83 291

9600 1.75 2.30 453

9610 0.97 1.28 341

9620 1.85 2.43 467



Effective Date 10/01/18

FOOTNOTES

(a) Loss Cost for each individual risk shall be obtained from the Rating Board.

(c) Refer to Miscellaneous Values page for Loss Costs

(e) Refer to Miscellaneous Values page for Loss Costs F Loss Cost provides coverage under the United States Longshore & Harbor Workers' Compensation Act PC Loss Cost is per capita PL Loss Cost is per location T Code is scheduled to be discountinued, effective October 1, 2022

CLASS CODES WITH SPECIFIC FOOTNOTES

* 7380 Ex-Medical Loss Cost for this classification is 6.16 & 8810 Ex-Medical Loss Cost for this classification is 0.09 @ 8833 Ex-Medical Loss Cost for this classification is 1.00 # 9040 Ex-Medical Loss Cost for this classification is 3.36 § 9048 Camps: Any adjustment in tuition fee made in consideration of services rendered shall not be considered as remuneration.

N The table below displays codes which have a corresponding non ratable element. The ratable and non-ratable components should be considered jointly when determining premium.

CLASS CODE NON-RATABLE ELEMENT CODE

4771 0771

7405 7445

7431 7453




MISCELLANEOUSVALUES *Ambulance-Volunteer Service Company – Code 7370

Applicable in accordance with Manual Rule II-G3 Ambulance – Rate ..................................................................................................................... $5,460 Each additional Ambulance – Rate ........................................................................................... $2,730

For a group policy subject to the provisions of Section 32.2 of the Volunteer Ambulance Workers' Benefit Law, premium is determined based on a charge for the first ambulance plus the additional ambulance charge for each additional ambulance covered by the group policy.

See Manual rule regarding the application of this charge to antique ambulances.

*Construction Employment Geographic Territories and Differentials # Territory 1 – Counties of the Bronx, Kings, New York, Queens and Richmond .................................. 0.0% Territory 2 – Counties of Dutchess, Nassau, Orange, Putnam, Rockland, Suffolk and Westchester . 0.0% Territory 3 – All Other Counties ........................................................................................................... 0.0%

# Location of work actually performed determines the territory for premium determination purposes. Territory Differentials are to be applied to each portion of an affected classification's manual premium corresponding to the payroll lrelated to work performed in each territory. Refer to Rule VI.I.

*DeductibleProgram

Deductible applies on a per occurrence basis.

DEDUCTIBLE A B C D E F G

$100 0.20% 0.20% 0.10% 0.10% 0.10% 0.10% 0.10%

$200 0.40% 0.30% 0.30% 0.20% 0.20% 0.20% 0.20%

$300 0.60% 0.50% 0.40% 0.40% 0.30% 0.30% 0.20%

$400 0.70% 0.70% 0.50% 0.50% 0.40% 0.30% 0.30%

$500 0.90% 0.80% 0.60% 0.60% 0.50% 0.40% 0.40%

$1,000 1.70% 1.50% 1.20% 1.10% 1.00% 0.80% 0.70%

$1,500 2.50% 2.20% 1.70% 1.60% 1.40% 1.10% 1.00%

$2,000 3.20% 2.80% 2.20% 2.00% 1.80% 1.40% 1.20%

$2,500 3.80% 3.40% 2.70% 2.40% 2.20% 1.70% 1.50%

$5,000 6.80% 6.10% 4.90% 4.40% 4.00% 3.10% 2.80%

*Expense Constant An expense constant shall be charged for each policy, regardless of premium size, except for those policies that insure Per Capita classification operations only. Refer to Rule XIV-F for special instructions concerning policies insuring only Per Capita classifications. Expense constants are carrier specific.




*Maximum Remuneration

Executive Officers Non-Construction Employments - applicable in accordance with Manual Rule IX-A-6-a2 .................... $2,150.00 Construction Employments – refer to Manual Rule IX-A-6-a7 ............................................................. $1,357.11*

Non-Executive Officers Applicable in accordance with Manual Rule V-F for classifications With footnotes limiting the maximum remuneration............................................................................... $5,725.00 Construction Employments – refer to Manual Rule V-G ...................................................................... $1,357.11*

Sole Proprietors and Partners Non-Construction Employments – applicable in accordance with Manual Rule IX-B-4a ...................... $2,150.00 Construction Employments – refer to Manual Rule IX-B-4b ................................................................. $1,357.11*

*Effective July 1, 2018 *Minimum Remuneration

Executive Officers Applicable in accordance with Manual Rule IX-A-6-a1 .............................................................................$725.00 Executive Officers of not-for-profit unincorporated associations Applicable with Manual Rule IX-A-6-b .......................................................................................................$350.00 Sole Proprietors and Partners Applicable in accordance with Manual Rule IX-B-4a and 4b .....................................................................$725.00

New York State Assessment Charges .................................................................................................................... 12.10% General Instructions and Information

Refer to Rule IX-L., Sections 1. and 2.




*Premium Base Refer to Rule IX-L., Section 3.

Standard premium is the only premium base to be used in calculating the New York State Assessment policy holder charge. For policy holder assessment purposes, standard premium is defined as the premium determined on the basis of the insurer’s approved rates, as modified by any experience modification or merit rating factor, any applicable territory differential premium, the minimum premium, any Construction Classification Premium Adjustment Program credits, any credit from return to work and/or drug and alcohol prevention programs, including credits under the Workplace Safety Loss Prevention Incentive Program (WSLPIP), any surcharge or credit from a work place safety program, including credits under the Workplace Safety Loss Prevention Incentive Program (WSLPIP), any credit from independently-filed insurer specialty programs (for example, alternative dispute resolution, drug-free workplace, managed care or preferred provider organization programs), any charge for the waiver of subrogation, any charge for foreign voluntary coverage and the additional charge for terrorism, and the charge for natural disasters and catastrophic industrial accidents. For purposes of determining standard premium, the insurer’s expense constant, including the expense constant in the minimum premium, the insurer’s premium discount and premium credits for participation in any deductible program shall be excluded from the premium base.

*Terrorism and Catastrophe Rate Charges Terrorism

Applicable only in conjunction with Rule IX-N.1 of the Manual Terrorism Rate charge per $100 of total policy payroll................................................................ $0.06

For non-payroll based classes, charge is % of non-payroll class manual premium ..................... 3.4%

Natural Disasters and Catastrophic Industrial Accidents

Applicable only in conjunction with Rule IX-N.2 of the Manual Catastrophe rate charge per $100 of total policy payroll ............................................................. $0.01 For non-payroll based classes, charge is % of non-payroll class manual premium ..................... 0.7%

*Workers Compensation Security Fund Surcharge Applicable only in accordance with Rule IX-M of the Manual

Charge is % of total policy premium, including the New York State Assessment ........................ 0.0%

*United States Longshore and Harbor Workers' Compensation Coverage Percentage Applicable only in connection with Rule XII-D of the Manual ...................................................................... 77.8%

(Multiply a Non-F classification rate by a factor of 1.294 to adjust for differences in state and federal benefits and assessments)




*Rates for Volunteer Firefighters – Code 7711

POPULATION ANNUAL RATES POPULATION ANNUAL

RATES POPULATION ANNUAL RATES

Up to 300 $5,729 3,501 to 4,000 $30,226 8,001 to 8,500 $61,671

301 to 500 $6,598 4,001 to 4,500 $34,583 8,501 to 9,000 $65,560

501 to 700 $8,713 4,501 to 5,000 $37,210 9,001 to 9,500 $69,578

701 to 1,000 $10,949 5,001 to 5,500 $39,826 9,501 to 10,000 $73,435

1,001 to 1,500 $14,501 5,501 to 6,000 $43,359 10,001 to 15,000 $87,084

1,501 to 2,000 $16,178 6,001 to 6,500 $46,890 15,001 to 20,000 $100,606

2,001 to 2,500 $20,136 6,501 to 7,000 $51,185 20,001 to 25,000 $113,663

2,501 to 3,000 $21,856 7,001 to 7,500 $54,693 25,001 to 35,000 $133,846

3,001 to 3,500 $26,242 7,501 to 8,000 $58,195 35,001 to 50,000 $167,624

For populations over 50,000, the annual rate shall be $220,593 plus $34,611 for each 10,000 people or major part thereof. For All Population Groups

Minimum premium................................................................................................................................. $7,539.00

A. The premium charge for the "home area" shall be the sum of:

1. The premium charge corresponding to the population of the "home area"

and

2. A premium charge of $151 per fire protection contract where the "home area" has obligated itself to provide

protection to another "home area" pursuant to a fire protection contract,

and

3. The separate premium charges for each "outside area" corresponding to the population of each such "outside area" that is serviced by the "home area" under a fire protection contract. However, when a "outside area" has more than one contract for fire protection, the additional premium charge for each "home area" providing fire protection to such" outside area" shall be a proportionate share of the total premium corresponding to the population of the "outside area, "provided that the books and records of the "home area" are maintained so as to show separately its contract price as well as the total cost of all contracts being paid by the "outside area." The proportionate share shall be determined on the basis of the ratio that the contract price paid to the "home area" bears to the total contract price for all fire protection for such "outside area."

B. The premium charge where a fire company or fire department operates in, or is maintained jointly by, two or more

villages, towns, or fire districts, shall be the sum of the separate premium charges for each village, town or fire district, corresponding to the population of each such village, town or fire districts.




C. Section 30 of the Volunteer Firefighters' Benefit Law makes a county, city, town, village or fire district responsible for such benefits to volunteer fire fighters of fire departments or companies in their area. Employers Liability coverage is not automatically afforded under these circumstances to the fire departments or companies whose firefighters are covered by the municipality's policy. However, the municipality may elect to extend Employers Liability coverage for an additional 10% of that premium which is developed for the volunteer fire fighters of these fire departments or companies. Use endorsement WC 310607. This additional premium shall be assigned to Code 9850 "Premium for the Extension of Employers Liability Coverage to Additional Interests under a VBFL policy."

D. The premium charge for a group policy subject to the provisions of Section 32.2 of the Volunteer Firefighters' Benefit Law is determined on the basis of the aggregate population of all entities insured under the group policy. Refer to Rule II.F.2 of the Manual.

The terms "home area" and "outside area" used in Rule A above are defined as follows: "Home Area"

a. Any city, village, or fire districts, having its own fire department, or protected pursuant to a fire protection

contract with an incorporated fire company, located within the city, village or district.

b. Any town fire protection district or town fire alarm district protected pursuant to a fire protection contract with an incorporated fire company located within the town fire protection district or town fire alarm district.

c. The territory of a town located outside of a city, village, fire district, town fire protection of town fire alarm district, included within the area of operating set forth in the certificate of incorporation of an incorporated fire company located in such territory.

"Outside Area"

Any city, village or fire district, town fire protection district or town fire alarm district which either does not have its own fire department or an incorporated fire company located within its boundaries, and is protected pursuant to a fire protection contract.

Firefighters – Volunteer, including drivers Elective Coverage for Assistance from individual Volunteer Firefighters...................................................... 7716

*Premium Charge - $72 per policy

Merchants Preferred Insurance Company



Refer to the Footnote Page for additional information Effective Date 10/01/18


0005 3.06 3.63 599

0006 3.48 4.12 653

0007 2.41 2.86 515

0031 2.88 3.41 575

0034 3.76 4.46 691

0035 2.90 3.44 578

0042 6.24 7.39 875

0050 5.14 6.09 870

0106 9.57 11.34 875

0251 18.05 21.39 875

0771 N 6.75 8.00 875

0908 PC 155.29 184.02 234

0909 PC 211.66 250.82 301

0912 PC 832.31 986.29 1036

0913 PC 338.22 400.79 451

0917 5.39 6.39 875

1170 4.53 5.37 791

1320 6.03 7.15 875

1430 4.24 5.02 752

1438 9.03 10.70 875

1439 6.13 7.26 875

1452 7.63 9.04 875

1463 7.26 8.60 875

1470 12.25 14.52 875

1624 4.82 5.71 828

1701 6.05 7.17 875

1710 6.73 7.98 875

1741 6.42 7.61 875

1747 22.27 26.39 875

1748 10.39 12.31 875

1809 13.35 15.82 875

1810 10.04 11.90 875






1853 5.32 6.30 875

1860 13.68 16.21 875

1924 6.10 7.23 875

1925 8.64 10.24 875

2001 5.92 7.02 875

2002 5.58 6.61 875

2003 6.28 7.44 875

2014 5.01 5.94 853

2021 4.12 4.88 737

2039 6.48 7.68 875

2041 5.46 6.47 875

2065 4.39 5.20 772

2070 6.44 7.63 875

2081 12.76 15.12 875

2089 10.62 12.58 875

2095 8.47 10.04 875

2101 4.74 5.62 818

2105 7.84 9.29 875

2111 3.46 4.10 651

2112 9.75 11.55 875

2114 6.66 7.89 875

2121 4.55 5.39 793

2143 4.78 5.66 823

2150 12.40 14.69 875

2157 11.65 13.81 875

2172 3.71 4.40 684

2288 8.94 10.59 875

2302 3.08 3.65 602

2362 2.36 2.80 508

2380 10.26 12.16 875

2387 4.21 4.99 749

2388 3.28 3.89 628






2402 2.74 3.25 558

2413 4.67 5.53 808

2416 2.56 3.03 533

2417 3.73 4.42 686

2501 0.93 1.10 321

2503 1.13 1.34 347

2534 5.60 6.64 875

2553 2.99 3.54 589

2570 5.52 6.54 875

2571 3.90 4.62 708

2576 4.15 4.92 741

2578 3.35 3.97 637

2590 3.03 3.59 595

2591 5.55 6.58 875

2593 6.45 7.64 875

2594 7.13 8.45 875

2600 7.36 8.72 875

2623 4.46 5.29 782

2640 16.66 19.74 875

2660 2.97 3.52 587

2670 3.53 4.18 660

2683 5.65 6.70 875

2688 1.71 2.03 423

2689 1.08 1.28 341

2702 16.47 19.52 875

2710 7.45 8.83 875

2714 9.76 11.57 875

2731 5.64 6.68 875

2737 6.32 7.49 875

2759 13.27 15.72 875

2790 2.02 2.39 463

2802 7.83 9.28 875






2816 4.08 4.83 731

2817 4.66 5.52 807

2818 5.00 5.93 852

2835 3.10 3.67 604

2841 4.70 5.57 813

2881 3.35 3.97 637

2883 4.17 4.94 743

2913 5.01 5.94 853

2916 4.70 5.57 813

2923 2.12 2.51 476

2942 T 3.01 3.57 593

3004 6.07 7.19 875

3018 10.16 12.04 875

3022 9.46 11.21 875

3027 3.26 3.86 625

3028 14.22 16.85 875

3030 11.43 13.54 875

3040 11.20 13.27 875

3041 6.41 7.60 875

3042 4.96 5.88 847

3060 14.36 17.02 875

3064 7.93 9.40 875

3066 3.81 4.51 696

3067 3.74 4.43 687

3076 3.62 4.29 672

3081 7.17 8.50 875

3085 6.79 8.05 875

3110 14.42 17.09 875

3111 6.39 7.57 875

3113 2.20 2.61 487

3114 3.18 3.77 615

3118 2.84 3.37 571






3122 5.30 6.28 875

3126 16.00 18.96 875

3129 4.09 4.85 734

3132 2.52 2.99 529

3145 2.51 2.97 527

3146 2.00 2.37 461

3169 4.80 5.69 826

3179 2.77 3.28 561

3188 3.68 4.36 680

3190 3.37 3.99 639

3191 4.74 5.62 818

3200 3.44 4.08 649

3220 3.26 3.86 625

3227 32.33 38.31 875

3241 5.51 6.53 875

3257 3.87 4.59 705

3270 2.69 3.19 551

3307 4.36 5.17 769

3315 10.33 12.24 875

3336 2.58 3.06 537

3365 9.62 11.40 875

3372 3.29 3.90 629

3381 2.51 2.97 527

3383 0.62 0.73 280

3384 0.31 0.37 241

3385 1.20 1.42 356

3400 8.92 10.57 875

3507 3.63 4.30 673

3515 3.72 4.41 685

3548 2.74 3.25 558

3559 3.45 4.09 650

3561 2.95 3.50 585






3574 0.84 1.00 310

3581 2.05 2.43 467

3612 3.13 3.71 608

3620 5.97 7.07 875

3629 1.96 2.32 455

3632 3.84 4.55 701

3634 2.23 2.64 490

3635 3.15 3.73 610

3638 3.76 4.46 691

3642 2.49 2.95 525

3643 2.81 3.33 566

3647 5.53 6.55 875

3648 2.34 2.77 505

3681 1.60 1.90 409

3685 1.60 1.90 409

3686 2.24 2.65 492

3724 5.48 6.49 875

3726 10.98 13.01 875

3737 5.29 6.27 875

3807 6.20 7.35 875

3808 4.51 5.34 787

3821 9.74 11.54 875

3823 5.95 7.05 875

3824 6.30 7.47 875

3826 1.92 2.28 451

3827 6.43 7.62 875

3830 3.10 3.67 604

3832 3.58 4.24 666

3865 2.92 3.46 581

3881 (a) - -

4000 6.90 8.18 875

4024 4.70 5.57 813






4034 10.88 12.89 875

4038 3.65 4.33 676

4053 5.70 6.75 875

4061 5.00 5.93 852

4062 6.45 7.64 875

4101 3.71 4.40 684

4111 3.58 4.24 666

4112 2.14 2.54 479

4114 2.96 3.51 586

4130 8.55 10.13 875

4131 4.70 5.57 813

4133 2.52 2.99 529

4150 2.02 2.39 463

4207 1.39 1.65 382

4239 3.50 4.15 657

4240 5.50 6.52 875

4243 4.25 5.04 754

4244 3.00 3.56 592

4250 3.07 3.64 600

4251 3.03 3.59 595

4263 5.56 6.59 875

4273 3.76 4.46 691

4279 4.59 5.44 798

4282 0.51 0.60 266

4298 2.68 3.18 550

4299 2.75 3.26 559

4301 9.03 10.70 875

4304 9.95 11.79 875

4307 3.59 4.25 668

4310 3.33 3.95 635

4312 3.07 3.64 600

4351 2.37 2.81 509






4352 0.79 0.94 303

4360 0.35 0.41 245

4361 0.81 0.96 306

4362 0.58 0.69 276

4410 5.61 6.65 875

4420 13.28 15.74 875

4431 5.47 6.48 875

4432 2.35 2.78 506

4439 T 3.34 3.96 636

4452 3.82 4.53 698

4459 4.35 5.15 767

4470 4.36 5.17 769

4475 2.97 3.52 587

4476 2.25 2.67 494

4479 2.95 3.50 585

4493 5.95 7.05 875

4511 0.76 0.90 299

4557 1.87 2.22 444

4558 4.74 5.62 818

4568 3.45 4.09 650

4583 9.25 10.96 875

4597 3.01 3.57 593

4611 2.37 2.81 509

4628 1.95 2.31 454

4635 6.29 7.45 875

4653 2.78 3.29 562

4665 14.19 16.82 875

4692 1.16 1.37 351

4693 2.51 2.97 527

4710 3.76 4.46 691

4712 2.91 3.45 580

4720 4.83 5.72 829






4751 3.13 3.71 608

4771 N 4.45 5.27 780

4825 0.97 1.15 327

4828 2.10 2.49 474

4829 2.85 3.38 572

4902 4.09 4.85 734

4923 1.58 1.87 406

5000 21.41 25.37 875

5022 20.68 24.51 875

5037 30.74 36.43 875

5040 24.27 28.76 875

5057 17.36 20.57 875

5059 42.31 50.14 875

5069 33.68 39.91 875

5102 13.21 15.65 875

5160 5.28 6.26 875

5183 7.79 9.23 875

5184 8.77 10.39 875

5188 6.90 8.18 875

5190 5.67 6.72 875

5191 1.54 1.82 400

5192 4.36 5.17 769

5193 9.89 11.72 875

5213 19.61 23.24 875

5221 13.05 15.46 875

5222 9.91 11.74 875

5223 9.50 11.26 875

5348 8.82 10.45 875

5402 9.38 11.12 875

5403 15.69 18.59 875

5428 6.29 7.45 875

5429 8.02 9.50 875






5443 10.17 12.05 875

5445 9.65 11.44 875

5462 8.78 10.40 875

5473 26.19 31.04 875

5474 10.47 12.41 875

5479 7.55 8.95 875

5480 12.88 15.26 875

5491 3.34 3.96 636

5506 14.21 16.84 875

5507 7.96 9.43 875

5508 7.15 8.47 875

5536 7.50 8.89 875

5538 8.19 9.71 875

5545 21.84 25.88 875

5547 14.03 16.63 875

5606 4.49 5.32 785

5610 10.09 11.96 875

5645 11.13 13.19 875

5648 19.35 22.93 875

5651 7.48 8.86 875

5701 19.41 23.00 875

5703 31.42 37.23 875

5709 23.02 27.28 875

5951 1.03 1.22 334

5954 5.57 6.60 875

6003 11.71 13.88 875

6005 5.33 6.32 875

6017 3.35 3.97 637

6018 13.44 15.93 875

6045 5.17 6.13 874

6204 8.98 10.64 875

6216 9.71 11.51 875






6217 8.37 9.92 875

6229 5.95 7.05 875

6233 5.93 7.03 875

6235 8.37 9.92 875

6251 15.99 18.95 875

6252 3.68 4.36 680

6260 (a) - -

6306 10.77 12.76 875

6319 7.35 8.71 875

6325 7.60 9.01 875

6400 7.09 8.40 875

6504 4.63 5.49 804

6701 17.40 20.62 875

6801 F 35.58 42.16 875

6811 5.94 7.04 875

6824 F 15.06 17.85 875

6826 F 5.95 7.05 875

6834 5.05 5.98 858

6836 3.75 4.44 688

6843 F 8.56 10.14 875

6854 3.06 3.63 599

6872 F 24.13 28.59 875

6874 F 63.71 75.50 875

6875 F 106.19 125.84 875

6882 5.07 6.01 861

6884 45.93 54.43 875

6885 65.45 77.56 875

7016 6.76 8.01 875

7024 7.52 8.91 875

7038 2.94 3.48 583

7046 2.96 3.51 586

7047 13.37 15.84 875






7050 5.81 6.88 875

7090 3.27 3.87 626

7098 3.28 3.89 628

7099 5.84 6.92 875

7133 5.01 5.94 853

7197 9.56 11.33 875

7201 4.55 5.39 793

7207 5.22 6.19 875

7219 11.50 13.63 875

7231 9.35 11.08 875

7242 24.12 28.58 875

7309 F 5.64 6.68 875

7313 F 2.73 3.24 556

7317 F 28.63 33.93 875

7327 F 30.72 36.40 875

7333 5.41 6.41 875

7335 6.01 7.12 875

7337 10.68 12.66 875

7364 2.08 2.46 471

7366 F 9.80 11.61 875

7367 8.52 10.10 875

7368 8.43 9.99 875

7370 (c) - -

7377 9.26 10.97 875

7380 * 9.43 11.17 875

7390 17.96 21.28 875

7394 4.12 4.88 737

7395 4.59 5.44 798

7398 8.15 9.66 875

7403 6.49 7.69 875

7405 N 1.66 1.97 417

7421 0.82 0.97 307






7422 2.93 3.47 582

7431 N 0.62 0.73 280

7445 N 0.38 0.45 250

7453 N 0.36 0.43 247

7502 2.18 2.58 484

7515 2.19 2.60 486

7520 7.29 8.64 875

7536 8.37 9.92 875

7538 4.32 5.12 763

7539 1.65 1.96 416

7542 6.14 7.28 875

7580 5.77 6.84 875

7590 5.67 6.72 875

7600 7.57 8.97 875

7601 4.92 5.83 841

7610 0.25 0.30 233

7710 4.07 4.82 730

7711 (e) - -

7716 (e) - -

7720 2.50 2.96 526

7723 1.85 2.19 441

7855 5.25 6.22 875

7998 2.85 3.38 572

7999 2.42 2.87 516

8001 3.20 3.79 617

8006 1.83 2.17 439

8008 1.00 1.19 331

8012 1.64 1.94 413

8013 0.41 0.49 254

8016 0.62 0.73 280

8017 1.55 1.84 402

8018 3.87 4.59 705






8021 6.37 7.55 875

8025 1.62 1.92 411

8031 2.85 3.38 572

8032 1.08 1.28 341

8033 3.85 4.56 702

8034 5.69 6.74 875

8039 2.11 2.50 475

8043 1.23 1.46 361

8044 3.68 4.36 680

8046 3.75 4.44 688

8047 1.83 2.17 439

8048 5.71 6.77 875

8068 0.34 0.40 244

8069 0.74 0.88 297

8072 0.97 1.15 327

8090 0.84 1.00 310

8102 8.40 9.95 875

8103 5.70 6.75 875

8105 2.89 3.42 576

8106 6.95 8.24 875

8107 3.82 4.53 698

8111 4.33 5.13 764

8116 2.31 2.74 501

8199 3.50 4.15 657

8209 8.31 9.85 875

8215 6.95 8.24 875

8227 12.43 14.73 875

8232 6.65 7.88 875

8235 5.57 6.60 875

8263 9.75 11.55 875

8264 6.88 8.15 875

8265 10.54 12.49 875






8280 18.30 21.69 875

8288 4.30 5.10 761

8291 8.13 9.63 875

8292 5.08 6.02 862

8293 10.83 12.83 875

8350 9.54 11.30 875

8353 5.87 6.96 875

8381 2.67 3.16 548

8382 2.17 2.57 483

8385 8.95 10.61 875

8391 3.78 4.48 693

8392 3.05 3.61 597

8394 5.66 6.71 875

8500 8.05 9.54 875

8601 0.48 0.57 263

8709 F 28.82 34.15 875

8719 2.61 3.09 540

8720 2.29 2.71 498

8726 F 3.77 4.47 692

8731 2.98 3.53 588

8742 0.31 0.37 241

8745 6.38 7.56 875

8747 0.18 0.21 223

8748 1.32 1.56 372

8751 4.07 4.82 730

8755 0.65 0.77 285

8800 2.05 2.43 467

8802 1.32 1.56 372

8803 0.06 0.07 208

8809 0.22 0.26 229

8810 & 0.14 0.17 219

8820 0.13 0.15 217






8829 3.77 4.47 692

8831 1.38 1.64 380

8832 0.46 0.55 261

8833 @ 1.46 1.73 390

8838 0.54 0.64 270

8840 0.51 0.60 266

8854 4.83 5.72 829

8857 3.04 3.60 596

8864 3.39 4.02 642

8865 3.49 4.14 655

8866 3.04 3.60 596

8868 0.50 0.59 265

8869 0.97 1.15 327

8871 0.23 0.27 230

8901 0.10 0.12 213

9014 5.03 5.96 856

9015 1.87 2.22 444

9016 5.55 6.58 875

9019 3.92 4.65 712

9025 19.97 23.66 875

9026 4.71 5.58 814

9027 PL 13.84 16.40

9028 3.45 4.09 650

9029 5.79 6.86 875

9030 5.73 6.79 875

9040 # 5.04 5.97 857

9044 6.19 7.34 875

9048 § 2.71 3.21 553

9051 4.25 5.04 754

9052 3.47 4.11 652

9055 1.27 1.50 365

9058 4.01 4.75 723






9059 9.56 11.33 875

9060 1.80 2.13 434

9061 2.08 2.46 471

9063 1.10 1.30 343

9065 1.27 1.50 365

9071 2.03 2.41 465

9072 2.35 2.78 506

9074 1.32 1.56 372

9088 10.81 12.81 875

9089 0.46 0.55 261

9093 2.17 2.57 483

9101 3.27 3.87 626

9102 4.23 5.01 751

9149 1.74 2.06 427

9157 4.84 5.74 831

9158 2.08 2.46 471

9159 1.46 1.73 390

9160 1.58 1.87 406

9178 3.70 4.38 682

9179 7.72 9.15 875

9180 2.80 3.32 565

9182 1.64 1.94 413

9186 7.92 9.39 875

9220 8.83 10.46 875

9402 6.52 7.73 875

9403 13.32 15.78 875

9410 8.31 9.85 875

9501 2.06 2.44 468

9505 5.55 6.58 875

9519 4.75 5.63 819

9521 5.18 6.14 875

9522 1.85 2.19 441






9526 13.21 15.65 875

9527 32.89 38.97 875

9534 10.88 12.89 875

9539 11.51 13.64 875

9545 15.34 18.18 875

9549 3.50 4.15 657

9552 13.66 16.19 875

9553 7.28 8.63 875

9585 1.05 1.24 336

9586 0.63 0.75 283

9600 1.75 2.07 428

9610 0.97 1.15 327

9620 1.85 2.19 441




FOOTNOTES

(a) Loss Cost for each individual risk shall be obtained from the Rating Board.

(c) Refer to Miscellaneous Values page for Loss Costs

(e) Refer to Miscellaneous Values page for Loss Costs

F Loss Cost provides coverage under the United States Longshore & Harbor Workers' Compensation Act

PC Loss Cost is per capita

PL Loss Cost is per location T Code is scheduled to be discontinued, effective October 1, 2022

CLASS CODES WITH SPECIFIC FOOTNOTES

* 7380 Ex-Medical Loss Cost for this classification is 6.16

& 8810 Ex-Medical Loss Cost for this classification is 0.09

@ 8833 Ex-Medical Loss Cost for this classification is 1.00

# 9040 Ex-Medical Loss Cost for this classification is 3.36

§ 9048 Camps: Any adjustment in tuition fee made in consideration of services rendered shall not be considered as remuneration

N The table below displays codes which have a corresponding non ratable element. The ratable and non-ratable components hould be considered jointly whendeterminging premium.

CLASS CODE NON-RATABLE

ELEMENT CODE

4771 0771

7405 7445

7431 7453




MISCELLANEOUS VALUES * Ambulance - Volunteer Service Company - Code 7370

Applicable in accordance with Manual Rule II-G3 Ambulance – Rate...................................................................................................................................... $5,460 Each additional Ambulance – Rate ............................................................................................................ $2,730

For a group policy subject to the provisions of Section 32.2 of the Volunteer Ambulance Workers' Benefit Law, premium is determined based on a charge for the first ambulance plus the additional ambulance charge for each additional ambulance covered by the group policy.

See Manual rule regarding the application of this charge to antique ambulances.

* Construction Employment Geographic Territories and Differentials # Territory 1 - Counties of the Bronx, Kings, New York, Queens and Richmond ............................................ 0.0% Territory 2 - Counties of Dutchess, Nassau, Orange, Putnam, Rockland, Suffolk and Westchester ........... 0.0% Territory 3 - All Other Counties ..................................................................................................................... 0.0%

# Location of work actually performed determines the territory for premium determination purposes. Territory Differentials are to be applied to each portion of an affected classification's manual premium corresponding to the payroll related to work performed in each territory. Refer to Rule VI.I.

* Deductible Program

Deductible applies on a per occurrence basis.

DEDUCTIBLE A B C D E F G

$100 0.20% 0.20% 0.10% 0.10% 0.10% 0.10% 0.10%

$200 0.40% 0.30% 0.30% 0.20% 0.20% 0.20% 0.20%

$300 0.60% 0.50% 0.40% 0.40% 0.30% 0.30% 0.20%

$400 0.70% 0.70% 0.50% 0.50% 0.40% 0.30% 0.30%

$500 0.90% 0.80% 0.60% 0.60% 0.50% 0.40% 0.40%

$1,000 1.70% 1.50% 1.20% 1.10% 1.00% 0.80% 0.70%

$1,500 2.50% 2.20% 1.70% 1.60% 1.40% 1.10% 1.00%

$2,000 3.20% 2.80% 2.20% 2.00% 1.80% 1.40% 1.20%

$2,500 3.80% 3.40% 2.70% 2.40% 2.20% 1.70% 1.50%

$5,000 6.80% 6.10% 4.90% 4.40% 4.00% 3.10% 2.80%

* Expense Constant An expense constant shall be charged for each policy, regardless of premium size, except for those policies that insure Per Capita classification operations only. Refer to Rule XIV-F for special instructions concerning policies insuring only Per Capita classifications. Expense constants are carrier specific.




* Maximum Remuneration

Executive Officers Non-Construction Employments - applicable in accordance with Manual Rule IX-A-6-a2 ........... $2,150.00 Construction Employments - refer to Manual Rule IX-A-6-a7 .................................................... $1,357.11*

Non-Executive Officers Applicable in accordance with Manual Rule V-F for classifications

with footnotes limiting the maximum remuneration ................................................................ $5,725.00 Construction Employments - refer to Manual Rule V-G ............................................................. $1,357.11*

Sole Proprietors and Partners Non-Construction Employments - applicable in accordance with Manual Rule IX-B-4a .............. $2,150.00 Construction Employments - refer to Manual Rule IX-B-4b ........................................................ $1,357.11*

*Effective July 1, 2018

* Minimum Remuneration

Executive Officers Applicable in accordance with Manual Rule IX-A-6-a1 .................................................................... $725.00 Executive Officers of not-for-profit unincorporated associations Applicable with Manual Rule IX-A-6-b ............................................................................................. $350.00 Sole Proprietors and Partners Applicable in accordance with Manual Rule IX-B-4a and 4b ........................................................... $725.00

New York State Assessment Charges ................................................................................................ 12.10% General Instructions and Information

Refer to Rule IX-L., Sections 1. and 2.




* Premium Base Refer to Rule IX-L., Section 3.

Standard premium is the only premium base to be used in calculating the New York State Assessment policyholder charge. For policyholder assessment purposes, standard premium is defined as the premium determined on the basis of the insurer’s approved rates, as modified by any experience modification or merit rating factor, any applicable territory differential premium, the minimum premium, any Construction Classification Premium Adjustment Program credits, any credit from return to work and/or drug and alcohol prevention programs, including credits under the Workplace Safety Loss Prevention Incentive Program (WSLPIP), any surcharge or credit from a workplace safety program, including credits under the Workplace Safety Loss Prevention Incentive Program (WSLPIP), any credit from independently-filed insurer specialty programs (for example, alternative dispute resolution, drug-free workplace, managed care or preferred provider organization programs), any charge for the waiver of subrogation, any charge for foreign voluntary coverage and the additional charge for terrorism, and the charge for natural disasters and catastrophic industrial accidents. For purposes of determining standard premium, the insurer’s expense constant, including the expense constant in the minimum premium, the insurer’s premium discount and premium credits for participation in any deductible program shall be excluded from the premium base.

* Terrorism and Catastrophe Rate Charges Terrorism

Applicable only in conjunction with Rule IX-N.1 of the Manual Terrorism Rate charge per $100 of total policy payroll................................................................ $0.05

For non-payroll based classes, charge is % of non-payroll class manual premium ..................... 3.4%

Natural Disasters and Catastrophic Industrial Accidents

Applicable only in conjunction with Rule IX-N.2 of the Manual Catastrophe rate charge per $100 of total policy payroll ............................................................ $ 0.01 For non-payroll based classes, charge is % of non-payroll class manual premium ..................... 0.7%

* Workers Compensation Security Fund Surcharge Applicable only in accordance with Rule IX-M of the Manual

Charge is % of total policy premium, including the New York State Assessment ........................ 0.0%

* United States Longshore and Harbor Workers' Compensation Coverage Percentage Applicable only in connection with Rule XII-D of the Manual ...................................................................... 77.8%

(Multiply a Non-F classification rate by a factor of 1.294 to adjust for differences in state and federal benefits and assessments)




* Rates For Volunteer Firefighters - Code 7711

POPULATION ANNUAL RATES POPULATION ANNUAL

RATES POPULATION ANNUAL RATES

Up to 300 $5,729 3,501 to 4,000 $30,226 8,001 to 8,500 $61,671

301 to 500 $6,598 4,001 to 4,500 $34,583 8,501 to 9,000 $65,560

501 to 700 $8,713 4,501 to 5,000 $37,210 9,001 to 9,500 $69,578

701 to 1,000 $10,949 5,001 to 5,500 $39,826 9,501 to 10,000 $73,435

1,001 to 1,500 $14,501 5,501 to 6,000 $43,359 10,001 to 15,000 $87,084

1,501 to 2,000 $16,178 6,001 to 6,500 $46,890 15,001 to 20,000 $100,606

2,001 to 2,500 $20,136 6,501 to 7,000 $51,185 20,001 to 25,000 $113,663

2,501 to 3,000 $21,856 7,001 to 7,500 $54,693 25,001 to 35,000 $133,846

3,001 to 3,500 $26,242 7,501 to 8,000 $58,195 35,001 to 50,000 $167,624

For populations over 50,000, the annual rate shall be $198,634 plus $31,166 for each 10,000 people or major part thereof. For All Population Groups

Minimum premium................................................................................................................................. $6,789.00

A. The premium charge for the "home area" shall be the sum of:

1. The premium charge corresponding to the population of the "home area"

and

2. A premium charge of $136 per fire protection contract where the "home area" has obligated itself to provide

protection to another "home area" pursuant to a fire protection contract,

and

3. The separate premium charges for each "outside area" corresponding to the population of each such "outside area" that is serviced by the "home area" under a fire protection contract. However, when a "outside area" has more than one contract for fire protection, the additional premium charge for each "home area" providing fire protection to such "outside area" shall be a proportionate share of the total premium corresponding to the population of the "outside area," provided that the books and records of the "home area" are maintained so as to show separately its contract price as well as the total cost of all contracts being paid by the "outside area." The proportionate share shall be determined on the basis of the ratio that the contract price paid to the "home area" bears to the total contract price for all fire protection for such "outside area."

B. The premium charge where a fire company or fire department operates in, or is maintained jointly by, two or more villages, towns, or fire districts, shall be the sum of the separate premium charges for each village, town or fire district, corresponding to the population of each such village, town or fire districts.




C. Section 30 of the Volunteer Firefighters' Benefit Law makes a county, city, town, village or fire district responsible for such benefits to volunteer firefighters of fire departments or companies in their area. Employers Liability coverage is not automatically afforded under these circumstances to the fire departments or companies whose firefighters are covered by the municipality's policy. However, the municipality may elect to extend Employers Liability coverage for an additional 10% of that premium which is developed for the volunteer firefighters of these fire departments or companies. Use endorsement WC 31 06 07. This additional premium shall be assigned to Code 9850 "Premium for the Extension of Employers Liability Coverage to Additional Interests under a VBFL policy."

D. The premium charge for a group policy subject to the provisions of Section 32.2 of the Volunteer Firefighters' Benefit Law is determined on the basis of the aggregate population of all entities insured under the group policy. Refer to Rule II.F.2 of the Manual.

The terms "home area" and "outside area" used in Rule A above are defined as follows: "Home Area"

a. Any city, village, or fire districts, having its own fire department, or protected pursuant to a fire protection

contract with an incorporated fire company, located within the city, village or district.

b. Any town fire protection district or town fire alarm district protected pursuant to a fire protection contract with an incorporated fire company located within the town fire protection district or town fire alarm district.

c. The territory of a town located outside of a city, village, fire district, town fire protection of town fire alarm district, included within the area of operating set forth in the certificate of incorporation of an incorporated fire company located in such territory.

"Outside Area"

Any city, village or fire district, town fire protection district or town fire alarm district which either does not have its own fire department or an incorporated fire company located within its boundaries, and is protected pursuant to a fire protection contract.

Firefighters – Volunteer, including drivers Elective Coverage for Assistance from individual Volunteer Firefighters...................................................... 7716

* Premium Charge - $65 per policy

MU 7302 (07/17) Page 1 of 3

NEW YORK CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT PROGRAMAPPLICATION INSTRUCTIONS

1) Determine the classification code applicable to all employees of the business. This includes clerical workers, salespersons andexecutive officers (unless they are excluded from coverage) but does not include subcontractors and independent contractors.Eligible classification codes are shown below.

2) List each classification code on the application (unless the insurance carrier has already done so). This includes both eligibleand non-eligible classification codes. Any information that is not filled out or left blank, the application will not get processed andnot get credited as sent to the Rating Board.

3) Determine the limited payroll (excluding premium overtime pay, bonuses, commissions) and hours worked for each employeeperforming commercial work in accordance with the Payroll Limitation Law. For employees performing work on one or two-familyresidential housing, report the total gross wages and hours worked. The program uses the third quarter (July, August, andSeptember) payrolls as shown below:

Policy Effective Date Third Quarter Payroll LIMITED PAYROLLApril 1, 2014 thru March 31, 2015 2013 $1204.81April 1, 2015 thru March 31, 2016 2014 $1212.98April 1, 2016 thru March 31, 2017 2015 $1266.44April 1, 2017 thru March 31, 2018 2016 $1296.48April 1, 2018 thru March 31, 2019 2017 $1305.92April 1, 2019 thru March 31, 2020 2018 *

*To Be DeterminedNOTES ON ITEM #3(Premium overtime pay is the amount paid over and above straight time. As an example, if someone worked 40 hours @ $6 an hourand 2 hours @ $9 an hour, the employee should be included on the application for 42 hours @ $6 per hour ($252). The additional $3paid for the 2 hours of overtime is excluded as long as the payroll records are properly maintained.) (Overtime is included as straighttime not time and half.)

Total the payrolls and hours worked by classification code as well as by the type of work performed (residential or commercial). Listeach applicable classification code on the application showing the residential total payroll and the limited commercial payroll onseparate lines. This means that the same classification code could appear twice on the same application. Hours worked for non-eligibleclassification codes are not required. The payrolls of all employees are to be included, even those earning an hourly wage that is lessthan the minimum hourly wage for eligibility under the program ($23.25 per hour for policies effective 10/1/13 and later or $15.50 perhour for policies with effective dates prior to 10/1/13).

The program grants credits based on the average hourly wage for those classification codes eligible for the program. If an employerhas more than one policy which can be combined for experience rating purposes, include the total wages and hours worked for allpolicies on the application. An example of this would be wrap-up policies.

MU 7302 (07/17) Page 2 of 3

4) List each executive officer on a separate line showing the applicable classification code for each executive officer if they areincluded. Also indicate each executive officer's title (if the executive officer(s) are excluded from coverage, then no entry isrequired).

5) List the actual quarterly wages for each executive officer (if the executive officer(s) are excluded from coverage, then no entry isrequired). If the officer is included under a classification code that is eligible under the Payroll Limitation Law, use the limitedpayroll for that executive officer for the required 520 hours per quarter.

6) Sign, date and mail the application to: New York Compensation Insurance Rating Board Applications can also be entered733 Third Avenue our online system starting 3 monthsNew York, NY 10017 prior to renewal atAttention: Terry Gerics, Executive Assistant http://cpap.nycirb.org/

ELIGIBLE CLASSIFICATION CODES0042 5000 5059 5184 5221 5403 5462 5491 5538 5645 5709 6045 6233 6306 7536 9526 95493365 5022 5069 5188 5222 5428 5473 5506 5545 5648 6003 6204 6235 6319 7538 9527 95533724 5037 5102 5190 5223 5429 5474 5507 5547 5651 6005 6216 6251 6325 7601 95343726 5040 5160 5193 5348 5443 5479 5508 5606 5701 6017 6217 6252 6400 7855 95393737 5057 5183 5213 5402 5445 5480 5536 5610 5703 6018 6229 6260 6701 8227 9545

NOTE: This application must be received by the Rating Board three (3) months prior to the policy renewal effective date. The RatingBoard will accept and process an application if it is received between the policy effective and expiration date, however, it must beaccompanied by a letter stating the reason for the delay. The submission of a revised application must be received no later than one(1) year after the expiration date of the policy to which the credit applies.

Under no circumstances will an original application be accepted for any policy if it is received after the expiration date of the policy, norwill a revised application be accepted if it is received later than one (1) year from the expiration date of the policy to which the creditapplies. For short-term policies, the application must be received prior to the expiration date of the short-term policy.

A credit will not be calculated if any application is received beyond the required dates of receipt.

Or email to: [email protected]

MU 7302 (07/17) Page 3 of 3

NEW YORK WORKERS COMPENSATIONPREMIUM CREDIT APPLICATION

INSURED__________________________________________ COVERAGE ID NO._____________________________POLICY NO.________________ EFFECTIVE DATE_____________CARRIER _____________________ ___________(DO NOT LEAVE POLICY # BLANK) (DO NOT LEAVE CARRIER BLANK)

NOTICE: This application will not be processed unless it is signed and completed in its entirety. Contact your agent, broker,or insurance company if assistance is needed. If the application is not sent to the Rating Board three (3) months prior to

gwhy it was not sent in on time. If there is no letter with the application, it will not be processed.

1. Qualifications An insured must be experience rated for the policy period applied for and must have an average hourly wageof $23.25 or higher per hour under an eligible classification code, for policies effective 10/1/13 and later. For policies effectiveprior to 10/1/13, the average hourly wage must be $15.50 or higher. Include all eligible and non-eligible codes on theapplication.

2. Classification(s), Code(s), Total Wages Paid for residential work only or Limited Payroll for commercial work applicable to thePayroll Limitation Law, Total Hours Worked and calendar quarter reported must be indicated. Once completed, keep a copyfor yourself.

NOTE: Limited Payroll for commercial work means the weekly maximum (see attached) for work on structures other than oneor two family dwellings in accordance with the Payroll Limitation Law. If you perform commercial work under any eligiblecode(s) enter each employee for the weekly maximum only and their total hours worked (ex. 13 weeks × Limited Payroll (seeattached) = total wages).

3. Construction and non-construction wages must be included. DO NOT include the payrolls for subcontractors and independentcontractors. Include wrap-up payroll.

4.each executive officer are to be stated as 520 per quarter (if the executive officer(s) are excluded from coverage, then no entryis required).

CLASSIFICATION CODE 3RD QUARTER TOTALNEW YORK HOURSWAGES WORKEDPAID*

_______________________________ _______ _______________________ _______________________________________________ _______ _______________________ _______________________________________________ _______ _______________________ _______________________________________________ _______ _______________________ _______________________________________________ _______ _______________________ _______________________________________________ _______ _______________________ _______________________________________________ _______ _______________________ ________________

* EXCLUDING OVERTIME PREMIUM PAY. Overtime premium pay is the wage paid above the straight time hourly pay. Ex: Ifan employee earns $20/hr. but earns overtime pay at an hourly rate of $30, exclude the additional $10. Include the total hoursworked at straight time wage not time and one half.

The foregoing is based on actual wages and hours worked, as reflected in our payroll records, for the complete calendarquarter ending __________________________. Do not send payroll records or tax forms.

Any person who knowingly and with intent to defraud any insurance company or other person files anapplication for insurance or statement of claim containing any materially false information or concealsfor the purpose of misleading, information concerning any fact material thereto commits a fraudulentinsurance act, which is a crime and subjects such person to criminal and civil penalties.

NAME ________________________________________ TITLE_____________________________________________

SIGNATURE ____________________________TELEPHONE NUMBER __________________ DATE_______________

EMAIL ADDRESS ___________________________________________________________________________________________

mailto:[email protected]

Policy Number

Policy Period

WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY POLICY

PARTICIPATION DIVIDEND ENDORSEMENT

If you paid your premium as required by this policy and if the law allows it, we will share with you part ofour earnings. However, we will only share earnings with you as authorized by our Board of Directors forany of your covered workplaces.

Dividends cannot be guaranteed in advance as they are subject to declaration by the Board of Directors.

This endorsement changes the policy to which it is attached. This endorsement is effective on the datethe policy is issued unless otherwise stated.

Policy No. Issued to

By Merchants Mutual Insurance Company

Effective at 12:01 A.M.

Agent

Countersigned by

MU 81 41 06 05 Page 1 of 1

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