ࡱ> jli  bjbj )Fjjl(((8`t3OTTTTT333NNNNNNN$O  RN3/333NTTN3 TTN3NBBDXGTH f!(=^E(GO03OERRGоٷ LOSS COST DATA ENTRY DOCUMENT (EFFECTIVE AUG. 16, 2004) 1.This filing transmittal is part of Company Tracking #  2.If filing is an adoption of an advisory organization loss cost filing, give name of advisory organization and Reference/Item Filing Number Company NameCompany оٷ Number3.A.B. Product Coding Matrix Line of Business (i.e., Type of Insurance)Product Coding Matrix Line of Insurance (i.e., Sub-type of Insurance)4.A.B. 5. (A) COVERAGE (See Instructions) (B) Indicated % Rate Level Change (C) Requested % Rate Level ChangeFOR LOSS COSTS ONLY(D) Expected Loss Ratio(E) Loss Cost Modification Factor(F) Selected Loss Cost Multiplier(G) Expense Constant (If Applicable)(H) Co. Current Loss Cost Multiplier TOTAL OVERALL EFFECT 6.5 Year HistoryRate Change History7.YearPolicy Count% of ChangeEffective DateState Earned Premium (000)Incurred Losses (000)State Loss RatioCountrywide Loss RatioExpense Constants Selected ProvisionsA. Total Production ExpenseB. General Expense C. Taxes, License & Fees D. Underwriting Profit  & ContingenciesE. Other (explain)F. TOTAL  8. _____ Apply Lost Cost Factors to Future filings? (Y or N) 9. _____ Estimated Maximum Rate Increase for any Insured (%). Territory (if applicable): _____________________________ 10. _____ Estimated Maximum Rate Decrease for any Insured (%) Territory (if applicable): _____________________________ PC RLC U:LossCostDraft/DataEntry.doc #=?Byz{|   1467=>@7MTUW]:BC_`ݴɴɴ}}t}}ɴp5\CJOJQJ^J5CJOJQJ\^JCJOJQJ^J" *5B*CJOJQJ\^Jph5B*CJOJQJ\^Jph5CJOJQJ\^JCJOJQJ^JCJOJQJ^JB*OJQJ^Jph5OJQJ\^J OJQJ^JCJOJQJ^J5CJCJ\,=>?Byz{|  ga !$$IflF6 06    4 lal$If $$Ifa$^     0~xrrii $$Ifa$$If !$$IflF6 06    4 lal01478;<i0````` $$Ifa$$$Ifl\K6lm 064 lal<=>?@VPJJDD$If$If !$$IflUrK6m@064 lali0````` $$Ifa$$$Ifl\K6lm 064 lalVTTKKKKK $$Ifa$$$IflUrK6m@064 lal #-4AUVe$$Ifl4\p6`p``"064 lal $$Ifa$ VWXY]^grv $$Ifa$$If"$$If$$Ifl4ִp!J(/6 " " "06    4 lal  $$Ifa$   #$$If$$Iflִp!J(/6p06    4 lal    $$Ifa$#$$If$$Iflִp!J(/6p06    4 lal $$Ifa$#$$If$$Iflִp!J(/6p06    4 lal !"#$ $$Ifa$$%&#$$If$$Iflִp!J(/6p06    4 lal&'()*+,- $$Ifa$-./#$$If$$Iflִp!J(/6p06    4 lal/0123456 $$Ifa$67M#x$If$$Iflִp!J(/6p06    4 lalMNOPQRSTUVW]lFf$IfFf $$Ifa$%9:;<=>?@ABC_`abcdefgFfp$If$IfFfH $$Ifa$`aij     ! " I J K L M N Q X    i CJOJQJ^J5>*CJOJQJ\^JCJOJQJ^JCJOJQJ^J5CJOJQJ\^JCJOJQJ^J0ghij݌Ff Ff $$Ifa$$If $$Ifa$    xFfFf $$Ifa$$If $$Ifa$           ! " I J K L <^<Ffd $$Ifa$Ff< $$Ifa$$If'&P1h0= /!"#$%$$Iflִp!J(/6p P06    4 lal*$$Ifl  *B; h&p'16 b ,| 06,,,,4 lal&$$Ifl  B; h&p'16 | 06,,,,4 lal&$$Ifl  B; h&p'16 | 06,,,,4 lal&$$Ifl  B; h&p'16 | 06,,,,4 lal&$$Ifl  B; h&p'16 | 06,,,,4 lal*$$Ifl  B; h&p'16 | 06,,,,4 lal&$$Ifl  B; h&p'16 | 06,,,,4 lal&$$Ifl  B; h&p'16 | 06,,,,4 lal&$$Ifl  B; h&p'16 | 06,,,,4 lal i8@8 NormalCJ_HaJmH sH tH N@N Heading 1$$0@&^0a$5CJOJQJ^JB@B Heading 4$@&5CJOJQJ\^J6@6 Heading 8$@& 5CJ\<A@< Default Paragraph Font.P@. Body Text 2CJ,@, Header  !, @, Footer  ! F=>?Byz{|    01478;<=>?@ #-4AUVWXY]^grv      !"#$%&'()*+,-./01234567MNOPQRSTUVW]l%9:;<=>?@ABC_`abcdefghij !"IJKL 00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000`  0<V  $&-/6Mg   !" 8@0(  B S  ?u%HKLMjx333333 bcardU:\LossCostDraft\DataEntry.docbcard(U:\LossCostRevised08-16-04\DataEntry.docbcard2C:\Data\Winword\AutoRecovery save of DataEntry.asdbcard(U:\LossCostRevised08-16-04\DataEntry.docbcard(U:\LossCostRevised08-16-04\DataEntry.docbcard,W:\RESEARCH\LossCostRev8-16-04\DataEntry.docHE7{@ nh7 pMȪb[6!JLo!Lt$"4;k@2@ r9cA  eEdyRD)G"%]D2g :Nok"Qw4U`V^`o(.dd^d`.4L4^4`L.  ^ `.  ^ `.L^`L.tt^t`.DD^D`.L^`L.88^8`5o(.^`. L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L.^`o((.0^`o((.@ 0@ ^@ `0o((..0^`0o((... 0^`0o( (.... ^`o( (..... ^`o((...... ^`o((....... `^``o((........l^`lo(.tt^t`.DLD^D`L.  ^ `.  ^ `.L^`L.^`.TT^T`.$L$^$`L.0^`0o(.^`. L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L.^`o(.tt^t`.DLD^D`L.  ^ `.  ^ `.L^`L.^`.TT^T`.$L$^$`L.^`o(.tt^t`.DLD^D`L.  ^ `.  ^ `.L^`L.^`.TT^T`.$L$^$`L.} } ^} `o((.0M M ^M `o((.0^`0o((..0^`0o((... ^`o( (.... ^`o( (..... ^`o((...... !`!^!``o((....... $`$^$``o((........88^8`5o(.^`. L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L.^`.h^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.88^8`5o(.^`. L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L.^`o(.^`.L^`L.  ^ `.k k ^k `.;L;^;`L.  ^ `.^`.L^`L.88^8`>*o(.^`. L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L.  ^ `o((.0  ^ `o((.g0g^g`0o((..707^7`0o((... oo^o`o( (.... ??^?`o( (..... ^`o((...... G"`G"^G"``o((....... %`%^%``o((........@^`@5o(.88^8`.L^`L.  ^ `.  ^ `.xLx^x`L.HH^H`.^`.L^`L.A /A ^A `/o(.0 / ^ `/o(.0^`0o(..0^`0o(... 0^`0o( .... ^`o( ..... ^`o( ...... !`!^!``o(....... $`$^$``o(........^`o(.tt^t`.DLD^D`L.  ^ `.  ^ `.L^`L.^`.TT^T`.$L$^$`L.7 p{@ b[6!t$"7 eERD)GcA%]r9U:NoHE"QwD2gk@2JLo!Cl        .        &         B        jn        .Թ        jV                 82        c        v        88        V        ?Byz{|    01478;<=>?@AUVWXYr      !"#$%&'()*+,-./01234567MNOPQRSTUW]l%9:;<=>?@ABC_`abcdefghij !"IJK@KK%8KK@UnknownGz Times New Roman5Symbol3& z Arial"hʡfʡfʡf5 Yn+202Q"NAIC LOSS COST DATA ENTRY DOCUMENTbcardbcardOh+'0 $0 L X d p|#оٷ LOSS COST DATA ENTRY DOCUMENTsAICbcardOScarcar Normal.dotObcard.d2arMicrosoft Word 9.0 @F#@&!@p_!@p_!5՜.+,0 hp  оٷS  #оٷ LOSS COST DATA ENTRY DOCUMENT Title  !"#%&'()*+,-.0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXZ[\]^_`bcdefghkRoot Entry Ff!mData $1Table/RWordDocument)FSummaryInformation(YDocumentSummaryInformation8aCompObjjObjectPoolf!f!  FMicrosoft Word Document MSWordDocWord.Document.89q