FORM 1024B (ED: 6/28/99)
Insurer Name:
Date:
NAIC Number:
INSURER RATE FILING
ADOPTION OF RATE SERVICE ORGANIZATION PROSPECTIVE LOSS COSTS
SUMMARY OF SUPPORTING INFORMATION FORM
CALCULATION OF COMPANY LOSS COST MULTIPLIER
1. Line, Subline, Coverage, Territory, Class, etc. combination to which this page applies:
2. LOSS COST MODIFICATION FACTOR:
A. The insurer hereby files to adopt the prospective loss costs in the captioned reference filing:
(CHECK ONE)
Without modification. (factor = 1.000)
With the modification(s) factor shown below in 2(B). Please describe the nature (e.g., applies only to
certain classifications) below and attach supporting data for the modification.
B. Loss Cost Modification Expressed as a Factor (LCMF):
(See examples below)
Example 1: If insurer’s loss cost modification is -10%, then the LCMF is .90 (1.000 -.100).
Example 2: If insurer’s loss cost modification is +15%, then the LCMF is 1.15 (1.000+150).
3. LOSS COST ADJUSTMENT: Development of Expected Loss Ratio. (Attach exhibit detailing insurer expense data
and/or other supporting information.)
Selected Provisions
A. Total Production Expense %
B. General Expense %
C. Taxes, Licenses & Fees %
D. Underwriting Profit & Contingencies %
E. Other (explain) %
F. Total %
4. DEVELOPMENT OF LOSS COST MULTIPLIER:
4A. Expected Loss Ratio: ELR=100% - 3F = %
4B. ELR in decimal form =
4C. Company Formula Loss Cost Multiplier: (2B ÷ 4B) =
5. Company Selected Loss Cost Multiplier =
Explain any differences between 4C and 5:
6. Rate level change for the coverages to which this page applies %
