WORKERS COMPENSATION EXPERIENCE RATING Risk Name: DODGE CO BD OF ED Risk ID: 100267381 Rating Effective Date: 01/01/2015 State Wt SRP GA .17 Exp Excess Losses 0 (D) Expected Losses 149,750 Exp Prim Losses 213,401 149,750 (A) (B) (C) Exp Excess Wt Losses (D - E) .17 Expected Losses Act Exc Losses 63,651 (E) Exp Prim Losses 213,401 C * (1 - A) + G 109,855 Actual (E) 560,042 (H) Act Inc Losses 145,681 (I) Act Prim Losses 523,452 109,855 Totals 70,311 352,384 (K) 25,458 SARAP Act Prim Losses (J) (A) * (C) 172,218 FLARAP Act Inc Losses Ratable Excess 172,218 63,651 ARAP 47,925 (A) * (F) C * (1 - A) + G Expected 47,925 (G) Ballast 413,597 Stabilizing Value State: GEORGIA Ballast 414,361 (F) Act Exc Losses (H - I) 63,651 Primary Losses (I) Production Date: 09/19/2014 261,327 MAARAP Exp Mod (J) / (K) 1.35 Factors RATING REFLECTS A DECREASE OF 70% MEDICAL ONLY PRIMARY AND EXCESS LOSS DOLLARS WHERE ERA IS APPLIED. Carrier: 58912 - 010 Policy: 14WC19 Eff-Date: 01/01/2014 Exp-Date: 01/01/2015 Copyright 1993-2014, All rights reserved. This experience modification factor is comprised of compilations and information which are the proprietary and exclusive property of the National Council on Compensation Insurance, Inc. (NCCI). No further use, dissemination, sale, transfer, assignment or disposition of this experience rating modification factor or any part thereof may be used without the written consent of NCCI. NCCI makes no representation or warranty, expressed or implied, as to any matter whatsoever including but not limited to the accuracy of any information, product or service furnished hereunder and, as to NCCI, recipient of this experience rating modification factor subscribes to and utilizes the information service “as is”. V - Page 1 of 2 WORKERS COMPENSATION EXPERIENCE RATING Risk Name: DODGE CO BD OF ED Risk ID: 100267381 Rating Effective Date: 01/01/2015 10-GEORGIA Carrier: Code Firm ID: 37044 ELR DRatio Production Date: 09/19/2014 Firm Name: DODGE CO BD OF ED Policy No. 900000005385111 Payroll State: GEORGIA 01/01/2011 Eff Date: Exp Prim Losses Expected Losses Claim Data Exp Date: IJ OF 01/01/2012 Act Inc Losses Act Prim Losses 2.07 .24 635,385 13,152 3,156 NO. 15 06 * 6,203 6,203 8868 .24 .31 16,427,881 39,427 12,222 0800680 06 F 13,299 13,299 9101 2.19 .31 1,066,334 23,353 7,239 0 0 7383 9812 ADDITIONAL PREMIUM Subject 18,129,600 Premium: Policy Total: 10-GEORGIA Carrier: Code 7383 Firm ID: 18910 ELR 2.07 DRatio Total Act Inc 145,195 Losses: Firm Name: DODGE CO BD OF ED Policy No. RWC3260304 Payroll .24 01/01/2012 Eff Date: Exp Prim Losses Expected Losses 669,452 19,502 13,858 Exp Date: 01/01/2013 Claim Data IJ OF Act Inc Losses 3,326 8588251 05 O 23,031 13,500 Act Prim Losses 8868 .24 .31 15,979,242 38,350 11,889 8422141 05 F 43,328 13,500 9101 2.19 .31 1,066,206 23,350 7,239 8424211 06 F 2,898 2,898 NO. 9 06 * 5,561 5,561 8345071 06 F 14,591 13,500 8388781 09 F 66,068 13,500 8392661 09 O 103,197 13,500 9812 ADDITIONAL PREMIUM Subject 17,714,900 Premium: Policy Total: 10-GEORGIA Carrier: Code Firm ID: 18910 ELR 0 DRatio Total Act Inc 135,846 Losses: 258,674 Firm Name: DODGE CO BD OF ED Policy No. RWC3285225 Payroll 0 01/01/2013 Eff Date: Exp Prim Losses Expected Losses Claim Data Exp Date: IJ OF 01/01/2014 Act Inc Losses Act Prim Losses 7383 2.07 .24 422,755 8,751 2,100 NO. 6 06 * 2,795 2,795 8868 .24 .31 13,476,758 32,344 10,027 10177971 06 F 6,925 6,925 20,816 6,453 11092521 09 O 36,374 13,500 0 0 9121191 09 F 68,388 13,500 9201941 09 O 167,384 13,500 9101 2.19 .31 950,481 9812 ADDITIONAL PREMIUM Policy Total: Subject 14,849,994 Premium: Total Act Inc 115,606 Losses: 281,866 Copyright 1993-2014, All rights reserved. This experience modification factor is comprised of compilations and information which are the proprietary and exclusive property of the National Council on Compensation Insurance, Inc. (NCCI). No further use, dissemination, sale, transfer, assignment or disposition of this experience rating modification factor or any part thereof may be used without the written consent of NCCI. NCCI makes no representation or warranty, expressed or implied, as to any matter whatsoever including but not limited to the accuracy of any information, product or service furnished hereunder and, as to NCCI, recipient of this experience rating modification factor subscribes to and utilizes the information service “as is”. * Total by Policy Year of all cases $2000 or less. C Catastrophic Loss D Disease Loss E Employers Liability Loss X Ex-Medical Coverage # Limited Loss U USL&HW V - Page 2 of 2
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