Report the numeric state code of the governing jurisdiction that will administer the claim and whose statutes will apply to the claim adjustment process.

Note: State Code “00” will no longer be accepted on any Unit Stat claim.

Note: For all claims subject to United States Longshore and Harbors Workers’ Compensation Act

(“USL & H”), Federal Employers Liability Act (“FELA”) and Admiralty State Code 59 must be used.

Refer to Part VI of this Plan for Jurisdiction State Codes.

1. Reporting Number and Valuation Date

   Code	Description
   1	Valued as of the 18th month after the month in which the policy became effective
   2	Valued 30 months after the month in which the policy became effective
   3	Valued 42 months after the month in which the policy became effective
   4	Valued 54 months after the month in which the policy became effective
   5	Valued 66 months after the month in which the policy became effective
   6	Valued 78 months after the month in which the policy became effective
   7	Valued 90 months after the month in which the policy became effective
   8	Valued 102 months after the month in which the policy became effective
   9	Valued 104 months after the month in which the policy became effective
   A	Valued 126 months after the month in which the policy became effective

    

2. Correction Type

   Indicates the type of correction report being submitted.  Applicable only to correction reports.

   Code	Description
   H	Header Record Correction
   E	Exposure Record Correction (First Reports Only)
   L	Loss Record Correction
   T	Total Record Correction Only
   M	Multiple Record Corrections

    

3. Exposure State

   The following state code number must be used:  New York – 31.

    

4. Policy Conditions

   Report the 1-position code for each policy condition.

    

   1. Multi-state Policy Indicator

      “Y” = Policy is a multi-state policy
      “N” = Policy is not a multi-state policy

       

   2. Interstate Policy Indicator

      “Y” = Policy is interstate rated
      “N” = Policy is not interstate rated

       

   3. Estimated Audit Code

      “Y” = Exposures expressed on unit report are estimated
      “N” = Exposures expressed on unit report are not estimated
      “U” = Exposures expressed on unit report are estimated – uncooperative insured

       

   4. Retrospective Rated Policy Indicator

      “Y” = Policy is retrospectively rated
      “N” = Policy is not retrospectively rated

       

   5. Canceled Mid-Term Indicator

      “Y” = Policy has been canceled mid-term 
      “N” = Policy has not been canceled mid-term

       

   6. Managed Care Organization Indicator

      “Y” = Policy has provisions for the administration of losses under an approved managed care organization or preferred provider organization
      “N” = Policy does not have provisions for the administration of losses by an approved managed care organization or preferred provider organization

5. Policy Type ID

   Identifies the type of coverage, plan indicator and non-standard provisions of the policy.

   1. Type of Coverage

      Code	Description
      01	Standard Workers’ Compensation Policy
      09	Non-Standard Policy

       

   2. Plan Type

      Code	Description
      01	Voluntary Policy

       

   3. Non-Standard Type

      Code	Description
      01	Non-Standard Code Does Not Apply
      02	Excluding Medical
      06	Excess Medical

6. Deductible Type

   Identifies the type of deductible being reported.

   1. Type of Deductible – First Two Positions

      Code	Description
      00	No Deductible
      01	Medical Losses Only
      02	Indemnity Losses Only
      03	Medical & Indemnity Losses

       

   2. Type of Plan – Second Two Positions

      Code	Description
      00	No Deductible
      01	Per Claim
      02	Per Accident
      03	Per Policy (Aggregate)
      04	Percent of Claim Cost
      05	Percent of Premium
      06	Coinsurance Only
      07	Benefit Coinsurance
      08	Per Accident Coinsurance
      09	Per Policy and Accident (Aggregate)
      10	Per Claim and Policy (Aggregate)
      11	Coinsurance Percent With Claim and Policy Aggregate Limits
      12	Variable

Jurisdiction State Code identifies the governing jurisdiction that administers the claim.