Workers’ Compensation Experience Modification Assessment Form
Evaluate factors that impact your workers’ compensation experience modification rate. Please complete all relevant sections for a comprehensive assessment.
Business/Employer Name
*
Policy Period (Start Date)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Industry Classification (NAICS or Description)
*
Annual Payroll (USD)
*
Number of Employees
*
Number of Workers’ Compensation Claims in the Last 3 Years
*
Average Cost per Claim (USD)
*
Current Experience Modification Rate (if known)
Safety & Risk Management Practices Evaluation
*
Rows
Not in Place
Partially in Place
Fully in Place
Written Safety Program
1
2
3
Regular Safety Training
4
5
6
Return-to-Work Program
7
8
9
Accident Investigation Procedures
10
11
12
Additional Comments or Relevant Information
Submit Assessment
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