Report the type of injury code as defined under provisions of the New York State Workers’ Compensation Law corresponding to the carrier’s estimate, as of the valuation date, of the ultimate injury type of the claim. The injury type does not have to correspond to the type of benefit being paid as of the valuation date; e.g., if temporary total payments are being made on a claim that is reserved as a permanent partial case, report the claim as a permanent partial injury type.

1. Death – Code 01

   Report each death claim unless it has been established that the carrier has incurred no liability.

   The amount reported as incurred indemnity must include all paid and outstanding benefits, including compensation paid to the deceased prior to death, burial expenses and payments to the state.

   If there is compensation paid prior to the death of a claimant and there is later found to be no liability on the death claim, the loss is to be reported on the basis of the injury for which payments have previously been made.

   Refer to Section (g) below for rules concerning the computation of death claim loss amounts that are payable to the Aggregate Trust Fund.

2. Permanent Total Disability – Code 02

   Report as permanent total disability each claim that constitutes permanent total disability under the New York State Workers’ Compensation Law, or that, in the judgment of the carrier, will result in permanent total disability.

   Refer to Section (g) below for rules concerning the computation of permanent total claim loss amounts that are payable to the Aggregate Trust Fund.

3. Permanent Partial Disability – Scheduled Loss of Use – Code 10

   A Scheduled Loss of Use permanent partial loss is defined as any permanent injury that does not involve permanent total disability and has been classified, or is expected to be classified, by the New York State Workers’ Compensation Board as a Scheduled Loss of Use, in accordance with Section 15, Paragraph 3 Items (a) through (v) of the New York State Workers’ Compensation Law, or if a claim has settled prior to such classification but was expected to be classified as such. Refer to this link for more information: Schedule Loss of Use Award.

   The amount entered as incurred indemnity must include specific benefits and compensation for temporary disability, as well as scheduled loss of use award.

   Note: For Permanent Partial claims that include or are expected to include both a Scheduled Loss of Use award and a Non-Scheduled award, report the injury type that generated the higher incurred indemnity loss amount.

4. Permanent Partial Disability – Non-Scheduled – Code 11

   A non-scheduled permanent partial loss is defined as any permanent injury that does not involve permanent total disability and has been classified, or is expected to be classified, by the New York State Workers’ Compensation Board as a non-scheduled permanent partial disability claim, in accordance with Section 15, Paragraph 3 Item (w) of the New York State Workers’ Compensation Law, or if a claim has settled prior to such classification but was expected to be classified as such. Refer to this link for more information: Schedule Loss of Use Award.

   The amount entered as incurred indemnity must include specific benefits and compensation for temporary disability, as well as loss of earning capacity.

   Refer to Section (g) below for rules concerning the computation of permanent partial claim loss amounts that are payable to the Aggregate Trust Fund.

   Note: For Permanent Partial claims that include or are expected to include both a Scheduled Loss of Use award and a Non-Scheduled award, report the injury type that generated the higher incurred indemnity loss amount.

5. Temporary Injury – Code 05

   Report as temporary every case that involves, or is expected to involve, indemnity benefits, but does not constitute a death case, permanent total disability or any permanent partial disability as defined above.

6. Medical Only – Code 06

   Report as medical-only claims that involve medical costs only and for which no indemnity costs have been incurred or are expected to be incurred as of the valuation date.

   When reporting claims involving medical-only losses, incurred and paid indemnity loss amounts must be $0.

   Incurred medical losses from claims not required to be reported to the New York State Workers’ Compensation Board, as defined in Section 110 of the New York State Workers’ Compensation Law, provided that the employer pays the claim in the first instance or immediately reimburses the carrier for the treatment rendered to the employee, should not be reported to the Rating Board.

   Note: An employer is not required to file a claim notice with the New York State Workers’ Compensation Board if the accident or illness requires ordinary first aid or causes loss of time from work of only one day beyond the working day or shift on which the accident or illness occurred.

    

7. Aggregate Trust Fund

   All death cases and designated permanent total and permanent partial disability cases are payable to the Aggregate Trust Fund as set forth in the New York State Workers’ Compensation Law. In determining the present value of the incurred loss amounts on these claims, the tables published in Bulletin 222C by the New York State Workers’ Compensation Board must be used. Refer to the New York State Workers’ Compensation Board for this Bulletin.

   When an award directing such payment has been made, include in the indemnity loss amount the fee charged by the Aggregate Trust Fund for the handling of such cases. This fee must not be included in the calculation of the present value of any case in which the final award has not yet been made.

   For all permanent total and permanent partial disability cases for which a life award is being made, but for which payments have not been designated for placement into the Aggregate Trust Fund, the tables shown below must be used in determining the present value for reporting under this Plan. For claims on policies effective prior to January 1, 2015, use Table-I. For claims on policies effective on or after January 1, 2015, Table I-M must be used for male claimants and Table I-F must be used for female claimants.

1999 United States Life Tables (U.S. Department of HHS) 3.5% Annual Rate of Interest

2007 United States Life Tables (U.S. Department of HHS) 3.5% Annual Rate of Interest

2007 United States Life Tables (U.S. Department of HHS)3.5% Annual Rate of Interest

Report the code that indicates the status of the claim as of the valuation date.

Open means that the carrier still expects to make further indemnity or medical payments on the claim (the exact nature of these payments is not known) or may not have determined as of the valuation date whether payments will be made in the future.

Reopened means that subsequent indemnity and/or medical payments have been made on a claim previously closed by the carrier or, due to a recent event, further indemnity and/or medical payments are expected and a reserve has been established for a claim previously closed by the carrier.

Closed means that the carrier does not expect to make any further indemnity or medical payment on the resolved claim.

Standard Policy means the standard provisions of the “Workers’ Compensation and Employers’ Liability Insurance Policy” (WC 00 00 00 C) and the “Information Page” (WC 00 00 01 A) approved by the New York State Department of Financial Services. Every policy affording coverage under the New York State Workers’ Compensation Law must include the following endorsements and premium elements.

MANDATORY ENDORSEMENTS

*These endorsements are not mandatory for the Volunteer Firefighters’ Benefit Law Policy and the Volunteer Ambulance Workers’ Benefit Law Policy.

Premium for each classification shown in the policy is determined by multiplying the basis of premium by the carrier approved rate.

All premiums should be shown to the nearest dollar. A remainder of $.50 or more shall be rounded to the next higher dollar.