Voluntary Premium Algorithm
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Voluntary Market Data Entry


Employer Name  
Effective Date
Expiration Date
Cancellation Date
Cancellation Type
Was policy issue short term to replace a binder or to establish concurrency with other policies?
Schedule Rating(xx.xx)
Waiver of Subrogation(xx.xx) Employers Liability
Small Deductible Programs applicable to Workers' Compensation only and not Employers Liability  
MA Benefits Deductible Program:
MA Benefits Claim & Aggregate Deductible Program:
Experience Modification(x.xx): Merit Rating:
MA Construction Credit(xx): ARAP Surcharge(x.xx):
Large Deductible Program applicable to both Workers' Compensation and Employer's Liability - not subject to experience rating(xx.xx):  
Premium Discount Carrier Type: QLMP Credit(xx.xx):
Admiralty/FELA Employers Liability Limits:
Audit Noncompliance Charge (ANC)(xx.xx):
DIA Assessment:






Enter Class Codes


Class Code*Exposure(Not subject to waiver)Exposure(Subject to waiver)USL&H Rate Deviation(xx.xx)
$  $   %
$  $   %
$  $   %
$  $   %
$  $   %
$  $   %
$  $   %
$  $   %
$  $   %
$  $   %

* Refer to the algorithm Part I (1): enter class codes for the following: admiralty/FELA classes, non-admiralty/FELA payroll classes, per capita classes, supplemental rate disease classes, supplemental non-ratable classes, and/or the supplemental rate atomic energy exposure.