Common Terms

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A
A.M. Best Company
A.M. Best rates insurance companies based on their financial condition and operating performance. Ratings are an industry standard to measure financial performance and strength. WCF Insurance was upgraded from an A- to an A (excellent) in 2008.
Accident Year
The year in which an injury occurred.
Accident Year Experience
The matching of accident year losses with accident year premium. Accident Year Experience changes as losses develop and premium finalizes.
Accident Year Losses
The losses that occurred during an accident year. Accident Year Losses, for a given year, change as claims develop. The ultimate Accident Year Losses is known once all claims that occurred during the given accident year are settled. In some cases, it could be 30-40 years before the ultimate losses are known.
Accident Year Premium
The combined premium that is attributed to the accident year. Accident Year Premium, for a given year, changes as premium adjusts in subsequent years. The ultimate Accident Year Premium is known once all premium adjustments are finalized. Accident Year Premium includes the pro rata portion of premium activity for the Accident Year.
Actuary
An individual that uses mathematical, accounting and statistical analysis of past loss data to project the value of future liabilities.
Adjudication
The process of resolving a controversy between parties by litigating the legal and/or factual issues. The court hearing the matter usually pronounces a judgment based on the presented evidence.
Adjuster
An individual that settles a claim filed by an insured. The adjuster evaluates the merits of a claim and determines the proceeds that might be payable for the claim.
Adjustment
The process of settling a claim. The settlement process includes evaluating the cause and amount of a loss, determining coverage and payment of any proceeds required under an insurance policy.
Admitted Assets
The assets that are permitted by a state to be used in determining the solvency, or financial condition of an insurance company.
Adjusting and Other Expenses (A&O)
The loss adjustment expenses that are not related to the defense, litigation, or cost containment of a claim. Includes the cost of adjusters. Also includes the cost of inspectors, appraisers, fraud inspectors, while working in the capacity of an adjuster. Prior to 1/1/98, Adjusting and Other Expenses were referred to as Unallocated Loss Adjustment Expenses (ULAE).
Agent
An individual authorized to represent an insurance company to sell insurance. A direct agent sells exclusively for one insurance company. An independent agent represents two or more insurance companies.
Aggregate Limit
The maximum amount an insurer will pay for all claims covered by a policy during a policy period.
Allocated Loss Adjustment Expenses (ALAE)
See Defense and Cost Containment Expenses
Anniversary Rating Date (ARD)
The date that is used to determining the effective rates on a policy. The date is usually the effective date of the policy, unless the rating board establishes a different date.
Annual Statement
The annual report that an insurance company is required to file with the state insurance department, in each state in which they do business. The report is compiled using statutory accounting principles (SAP) by using forms designed by the NAIC. The report provides information needed to assure that an insurance company has adequate reserves, and that the assets are available to meet all benefit payments for which they are liable.
Assigned Risk
A policyholder that is unable to obtain voluntary insurance coverage. Depending upon the state, to obtain coverage the policyholder is assigned to the carrier of last resort, or to a pool of participating insurers.
Association Credit
A premium discount provided to members of a trade association that has selected WCF Insurance as its workers' compensation insurance carrier of choice. Members must meet the program's requirements to obtain the discount.
Assume
The acceptance by a reinsurer (assuming company), of part or all of the written insurance transferred to it by the primary insurer or another reinsurer. Assumed premium is the premium received from risk transfer to a reinsurer. Assumed losses are the corresponding losses related to the Assumed premium.
Assuming Company
The reinsurance company that accepts risk from a primary insurer or another reinsurer.
Average Monthly Wage (AMW)
Form of calculating lost wage benefits due based on an employee’s monthly earnings.

 

B
Basic Premium
A percentage of the standard premium used in calculating the premium of a retrospectively rated policy. Basic Premium is the portion of the retrospective premium that is loaded to reflect a policy's expected overhead cost and profit.
Benefits
Monetary payments and other services provided by insurers under the terms of an insurance policy.
Bulk Reserves
An additional amount added to reserves to account for claim development that has not been included in the case reserves. Bulk Reserves can not be attributed to any individual claims, but are an adjustment related to all outstanding claims.

 

C
Calendar Year Experience
The matching of calendar year losses with calendar year premium. Calendar Year Experience does not change as losses develop and premium finalizes.
Calendar Year Losses
The combined losses that occurred during a calendar year. Calendar Year Losses do not change as claims develop in subsequent years. Calendar Year Losses include claim activity for the current year claims and additional claim activity for prior year claims that occurred during a given calendar year.
Calendar Year Premium
The combined premium that transpired during a calendar year. Calendar Year Premium, for a given year, does not change as premium adjusts in subsequent years. Calendar Year Premium includes premium activity for the current calendar year only, regardless of the policy period.
Cancellation
The termination of an insurance policy before its expiration date by either the insurance company or the policyholder.
Carrier of Last Resort
The insurance company designated to accept a policyholder after the policyholder has been refused coverage by all other insurance companies. The Carrier of Last Resort is usually a state fund. Not applicable in monopolistic states and in states that have assigned risk pools. WCF receives a federal tax exemption for being Utah's carrier of last resort.
Cede
To pass on to another insurance company (reinsurer) all or part of the insurance written by an insurer (ceding company), to reduce the possible liability of the reinsurer. Ceded premium is the premium paid for the transfer of risk to a reinsurer. Ceded losses is the corresponding losses related to the ceded premium.
Ceding Company
The insurance company that transfers risk to a reinsurer.
Certificate of Insurance
A document issued by an insurance company that provides evidence of the existence and terms of a policyholder's insurance coverage.
Claim
A request to an insurance company for payment of a loss covered by an insurance policy.
Claimant
An individual who submits a claim to an insurance company for an incurred loss.
Claims Outstanding (or Claims Pending)
The total number of open claims at any given time.
Claims Reserve
The reserves attributed to an individual outstanding claim. Claims Reserves contrasts with bulk reserves that can not be attributed to an individual claim, but are attributed to all outstanding claims. Claims Reserves are equal to total incurred less net payments (gross payments less subrogation).
Claims Severity
The average cost per claim. Severity can be based on accident year or policy year, for an individual policy, a group of policies or all policies.
Class Codes
A numerical index by type of business operations used in grouping similar type of risks for rating purposes. The Class Codes are designed so that businesses with similar characteristics are charged the same rate. The NCCI develops and maintains the class codes for workers' compensation insurance.
Collected Premium
The amount of premium that has actually been received as payment.
Combined Ratio
The sum of the loss ratio and expense ratio. The Combined Ratio indicates whether an insurance company is making a profit on the business it is writing, without taking into account the investment returns on the premium received.
Compromise and Release (C and R)
Full settlement of a California workers compensation claim, including past, present and future medical, lost wage and permanent impairment benefits as well as vocational rehabilitation.
Coverage A
A workers' compensation policy agreement under which an insurance company promises to pay all compensation and all benefits required of an insured employer under the workers' compensation act of the state or states listed on the policy
Coverage B
Coverage under a workers' compensation policy for situations in which an employee not covered under workers' compensation law could sue for injuries suffered under common law liability.

 

D
Date Of Injury (DOI)
The date of the accident that caused the injury.
Date of Knowledge (DOK)
The date an employer actually became aware of an injury sustained by an employee.
Death Benefits
Indemnity benefits paid to an eligible survivor of a worker whose injuries result in death. The benefits are usually paid until the surviving spouse remarries, or is determined to no longer be dependent on these benefits (often these benefits are paid for the remainder of the spouse's life). After the re-marriage of the spouse, or in the absence of a surviving spouse, Death Benefits will be paid to any surviving children until the age of 18.
Declarations Page (Dec Sheet)
The portion of a policy describing a risk. Includes the insured's name and address, policy term, policy premium, and amount of coverage.
Deductible
The amount of loss that the policyholder pays in a claim. The policyholder is liable to pay the Deductible before the insurance company is obligated to pay the claim. The policyholder receives a discount by adding the Deductible to the policy. The higher the Deductible, the lower the premium.
Defense and Cost Containment Expenses (D&CC)
The loss adjustment expenses that are related to the defense, litigation, or cost containment of a claim. Includes surveillance, appraisers, private investigators, and fraud investigators, if working in defense of a claim. Also includes rehabilitation nurses and the cost of engaging experts. Prior to 1/1/98, Defense and Cost Containment Expenses were referred to as Allocated Loss Adjustment Expenses (ALAE).
Deposit Premium
The premium paid at the beginning of the policy which provides for future premium adjustments based on an estimate of the final premium.
Disfigurement
Benefit awarded in Colorado if an injured worker sustains scarring or disfigurement as a result of a work injury.
Dividend
A payment to the policyholder by an insurance company out of its surplus or net worth.
Division Independent Medical Examination (DIME)
Examination by a physician in Colorado that has not previously treated an injured worker for a work injury in Colorado.  They physician provides an opinion regarding Maximum Medical Improvement (MMI) and whether permanent impairment was sustained.  The results of the examination are binding and can only be challenged through the legal process.
Division of Industrial Relations (DIR)
State agency regulating workers compensation insurance carrier practices and claim handling in Nevada.
Division of Workers Compensation (DWC or DOWC)
State agency regulating workers compensation insurance carrier practices and claim handling in California.  It is also the name of the state agency in Colorado.

 

E
Earned Premium
The pro rata portion of written premium applicable to the expired portion of the policy term for which the insurance was in effect.
Effective Date
The date coverage begins on an insurance policy.
Electronic Adjudication Management System (EAMS)
Computer-based case management system that simplified and improved the Division of Workers' Compensation (DWC) case management process in California.
Employee Leasing
See Professional Employer Organization
Employer's First Report of Injury (E-1)
A report that an employer is required to file with its workers' compensation carrier when one of its employees is injured while working. Also known as Labor Commission Form 122.
Employers Liability
Employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. The bodily injury must arise out of and in the course of the injured employee's employment by you.
Endorsement
A written amendment attached to a policy modifying the terms of the insurance contract. The modification can only become effective with the agreement of the insured, unless it is clearly made solely for the benefit of the insured.
Estimated Premium
The premium on a term policy calculated using estimated payroll exposure. Estimated Premium is the policy premium prior to the final premium calculation.
Expense Constant
A flat charge added to small account premiums to cover the cost of issuing and servicing a policy.
Expense Ratio
The percentage of premium used to pay for the acquisition, writing, and servicing of a policy. The Expense Ratio is equal to underwriting expenses divided by written premium. The Expense Ratio shows how much it costs the insurance company to write the premiums.
Experience Modification Factor (E-Mod)
A premium modifier that reflects the loss experience of a policyholder compared with payroll exposure during the same time period. The modifier increases or decreases the current premium depending on how the actual exposure and losses, for the past three years, compares with expected losses for the same amount of exposure. (Currently, to be eligible in Utah for an e-mod, the premium for two of the past three years must have been $3,500 or greater, or the premium for the past year must have been $7,000 or greater). E-Mods are calculated by the NCCI.
Expiration Date
The date coverage ends on an insurance policy.
Exposure
Being subject to the possibility of a loss. See Payroll Exposure.
Extraterritoriality
A provision in workers' compensation insurance law that extends protection to an employee that is injured in a state other than his state of hire.

 

F
Facultative Reinsurance
The reinsurance of part or all of a single policy. In Facultative Reinsurance, both the primary insurer and the reinsurer have the faculty or option to accept or reject the policy to be reinsured. Compare with treaty reinsurance.
Final Admission of Liability (FA)
The Final Admission of Liability is filed at the conclusion of a worker's compensation claim to summarize benefits admitted. The Final Admission notifies the injured worker of what action must be taken if they disagree with the admission including applicable deadlines.  If the injured worker does not timely object, then the claim closes.
Final Premium
The premium on a term policy calculated using actual payroll exposure. Final Premium is calculated after the policy has expired.
Frequency
The number of claims occurring. Frequency can be based on accident year or policy year, for an individual policy, a group of policies, or all policies.
Future Medical Care (FMC)
Medical treatment after Maximum Medical Improvement (MMI) necessary for an injured worker to maintain his or her MMI status.

 

G
General Admission of Liability (GA)
A General Admission of Liability is filed to admit liability for a workers compensation claim.  The General Admission states acceptance of the claim as compensable and admits liability for reasonable and necessary medical expenses related to the injury.  The General Admission may be notification of the admitted average weekly wage, the time period and rate of temporary disability benefits, medical benefits, and other benefits.
Governing Classification
A policyholder's workers' compensation class code that has the most payroll exposure. The Governing Classification generally describes the main business operation of an employer. The Governing Classification cannot be a standard exception, unless there are no other class codes other than the standard exceptions.

 

I
Idaho Industrial Commission (IIC)
State agency regulating workers compensation insurance carrier practices and claim handling in Idaho.
Imaging
The WCF Insurance department that scans and indexes policy and claims documents into TORIS.
Impairment Rating
A rating established by a claimant's physician that quantifies a claimant's physical disability. The Impairment Rating is determined by medical examinations, using American Medical Association (ADA) guidelines. Individual states may have additional guidelines that supersede the ADA guidelines. The Impairment Rating reflects the percentage of a claimant's whole body impairment.
Incurred But Not Reported (IBNR)
Covered losses that occurred but have not yet been reported to the primary insurance company. A reserve is set up to account for this unknown liability, to more accurately reflect the expected ultimate losses.
Incurred But Unpaid Benefits (IBUB)
The general liability accounts that reflect the reserves that have been booked to pay any future liabilities on outstanding claims and IBNR claims.
In-Force
When a policy is active and coverage is extended. Reflects the exposure for which an insurance company is providing insurance coverage.
Indemnity
Compensation for a loss.
Indemnity Claim
A claim which includes payments and reserves for lost wages and medical expenses. Indemnity claims occur when an injured worker is out of work long enough to receive compensation for lost wages.
Independent Contractor
An individual who does a job for another individual, or company, according to a contract and is not an employee of the individual, or company. An independent contractor has significantly more direction and control of how the work is completed, than an employee would have.
Independent Medical Examination (IME)
An examination of an injured worker by a physician selected by the insurance company. Independent Medical Examinations are usually done to determine the appropriateness of a course of treatment, or to provide an evaluation of permanent impairment.
Industrial Commission of Arizona (ICA)
State agency regulating workers compensation insurance carrier practices and claim handling in Arizona.
Initiation
The WCF Insurance department that enters the first report of injury and sets the claim up on the system.
Installment Premium
A partial payment of premium made by a policyholder for coverage on a term policy. The Installment Premium is determined by dividing the estimated premium into smaller amounts at set intervals during the policy period.
Insurance
The transfer of risk from one party (insured) to another party (insurer), in which the insurer promises to pay the insured (or others on behalf of the insured) an amount of money, or service, for losses sustained from an unexpected event, during a period of time for which the insured makes a premium payment to the insurer.
Insurance Commissioner
The official of a state charged with the duty of enforcing its insurance laws. Also called the superintendent of insurance and director of insurance.
Insured
The person(s) or party(ies) protected by an insurance policy.
Insurer
The insurance company or other organization providing insurance coverage and services to an insured.
Investment Income
Money earned from invested assets. An insurance company's invested assets usually include reserves and policyholder surplus. Net investment income is investment income less investment expenses. (Does not include realized, or unrealized, gains or losses).

 

L
Labor Commission
A state regulatory agency that oversees workers' compensation insurance in the state of Utah. The Labor Commission seeks to assure that employees in the state are covered for industrial injuries by assuring that employers have adequate workers' compensation coverage. The Labor Commission also oversees the payment of workers' compensation benefits in the state.
Lien
California’s workers’ compensation law allows certain claims for payment for services or benefits provided to or on behalf of injured workers to be filed as a lien against the injured worker’s claim for workers compensation benefits.  Payment of those claims can only be allowed by order of the Workers Compensation Appeals Board (WCAB).
Long-Tail Line
A line of insurance coverage where the occurrence and reporting of a loss and the payout of the claim is often spread out over a long period of time. The uncertainty of the length of the time period makes it difficult to determine the value of the claim when the claim is first reported.
Loss
1. The amount an insurer is obligated to pay because of an insured event. 2. An injury caused by an event covered by an insurance company.
Loss Adjustment Expenses (LAE)
All of the costs associated with the settlement of a claim. See Defense and Cost Containment Expenses and Adjusting and Other Expenses.
Loss Conversion Factor (LCF)
A multiplier used in calculating the premium of a retrospectively rated policy to include the cost of settling claims. Incurred losses are multiplied by the Loss Conversion Factor to obtain an amount equal to incurred losses plus loss adjustment expenses.
Loss Cost Multiplier
A factor an insurance company files with the state insurance department that reflects the increase, or decrease, in state rates that the insurance company will charge for workers' compensation. Currently in Utah, WCF Insurance files separate Lost Cost Multipliers for Preferred Rates, Standard Rates, and Non-Standard Rates.
Loss of Earning Capacity (LEC)
Benefit awarded to injured workers in Arizona that is provided in the event their wage being collected after an injury is less than wages prior to their injury.
Loss Ratio
The percentage of losses plus loss adjustment expenses to earned premium. The loss ratio shows how much premium was used to cover losses and the cost to settle the losses.
Loss Run
A report that lists the losses and expenses for the claims filed on a policy for a given period of time. A Loss Run also reports the premium earned for the period of time and the calculated loss ratio. A Loss Run also provides a breakdown of losses by paid, reserves, and subrogation. In addition, losses are broken down further by type of loss (medical and compensation) and type of expense (rehab: vocational rehabilitation and ALAE: defense and cost containment). Only expenses charged to a claim are listed on the loss run.
Losses Incurred
An amount representing the losses paid plus the change (positive or negative) in outstanding loss reserves within a given period of time. On the annual financial statement, Losses Incurred is the loss paid during the year plus the loss reserves at the end of the year less the loss reserves at the beginning of the year.
Lost Time (or "Time Loss") Claim
A claim in which an injured worker is determined by a doctor to be unable to work for a period of time (in Utah, the period must exceed three days). These claims involve the payment of disability benefits, in addition to medical costs and other expenses.

 

M
Manual Premium
Premium calculated by multiplying the exposure by the manual rate. Manual Premium is the premium before experience modification and premium discounts.
Manual Rate
The rate used to calculate premium on a policy. The Manual Rate is equal to the state rate multiplied by the appropriate loss cost multiplier (preferred, standard, non-standard) that was filed with the state insurance commissioner.
Maximum Medical Improvement (MMI)
The maximum level of medical improvement of an injured worker's condition. Once a claimant has obtained MMI, it is expected that significant improvements in the future will be minimal.
Medical Case Management
Professional services for the evaluation, monitoring and coordination of medical treatment of claims with specific diagnosis or requiring high-cost or extensive services.
Medical Only Claim
A claim which includes payments for medical expenses only. A medical only claim occurs when the injured worker was not out of work long enough to receive compensation for lost wages.
Medicare Set-Aside Agreement (MSA)
If injured worker is a Medicare beneficiary and their workers compensation claim is settled on a full and final basis then Medicare's interests need to be considered.  A portion of the settlement money is put into an account and used to pay for future medical treatment that Medicare would not pay if it was considered part of the work injury.
Micro Insurance Reserve Analysis (MIRA)
The automated claim reserving system in use at WCF Insurance that provides total incurred losses for a claim based on the criteria of a claim. About 90% of the claims are reserved by MIRA. The remaining claims reserves (usually catastrophic claims) are manually reserved to reflect more accurate reserves. MIRA is a software product of HNC Insurance Solutions.
Minimum Premium
The smallest premium charged by WCF Insurance to issue coverage for an annual period.
Modified Premium
Premium after the adjustment for experience modification.
Monopolistic State Fund
State operated insurance company that is the sole provider of workers' compensation insurance in a state. In these states, no other insurance companies are permitted to write workers' compensation insurance. Currently, there are five Monopolistic State Funds: North Dakota, Ohio, Washington, West Virginia and Wyoming.
Mutual Insurance Company
A company owned and controlled by its policyholders. A Mutual Insurance Company's surplus may be distributed to its policyholders in the form of a dividend.

 

N
National Association of Insurance Commissioners (NAIC)
An organization of state insurance commissioners that promotes uniformity by drafting regulations and model legislation. The NAIC has achieved considerable multi-state uniformity through the annual statement, which insurance company's use for financial reporting.
National Council on Compensation Insurance (NCCI)
An organization of insurance companies that write workers' compensation insurance. The NCCI collects statistics to establish rate structures so they can file rating plans with state insurance commissioners. The NCCI also maintains policy information and calculates e-mods for these policies.
Negligence
Failure to do the correct or prudent thing, whether by omission or commission, in a given situation, resulting in harm to another.
Net
After the application of an offset. Premium, net of reinsurance, is direct premium plus assumed premium, minus ceded premium. Losses, net of reinsurance, is direct losses plus assumed losses, minus ceded losses.
Net Investment Income
Money earned from invested assets less investment expenses. An insurance company's invested assets usually include reserves and policyholder surplus. (Does not include realized, or unrealized, gains or losses).
Net Investment Income Ratio
The percentage of net investment income to net earned premiums.
New Business
Written premium from a business that has been on WCF Insurance's books for the less than 12 months.
Non-Admitted Assets
The assets that are not permitted by a state to be used in determining the solvency, or financial condition of an insurance company.
Notice of Claim Status (NCS)
Idaho form used to notify injured workers of a change in their benefit status.  This form notifies a person if their benefits have been decreased or increased or if the claim has been denied and why.  Also known as a Change of Benefit (COB) form.  Arizona also has a NCS form that notifies injured workers of changes in benefit status.
Notice of Intent to Close (NITC)
Nevada form sent to the injured worker making them aware of the insurer’s intent to close their claim once all appropriate benefits have been paid.
Not Otherwise Classified (NOC)
A class code term denoting that the policyholder's operations cannot be classified more specifically.
Nurse Case Manager (NCM)
Medical provider such as a nurse sometimes hired by an insurance company to ensure the injured worker has an understanding of medical treatment being provided after an injury.

 

O
OCIP
See Owner Controlled Insurance Program
Occurrence
A repeated exposure or event which unexpectedly causes loss or damage.
Operating Ratio
The combined ratio less the net investment income ratio.
Owner Controlled Insurance Program (OCIP)
An insurance program written to cover large construction projects, usually exceeding $100 million in construction value. Under this program, all labor performed under the contract is covered. The program usually includes insurance policies covering workers' compensation and general liability. Also called "wrap-up" policies.

 

P
PEO
See Professional Employer Organization
Paid Losses
The actual amount of total losses paid by an insurance company.
Payment Plans
The payment of premium in periodic installments. The payment periods are usually monthly.
Payroll Exposure
A measurement of the amount of loss possibility to which an employer's workers are subject. Payroll Exposure is used to calculate the amount of premium that is due on a workers' compensation insurance policy.
Permanent Partial Disability (PPD)
An injured worker that has a permanent impairment rating of less than 100% after maximum medical improvement has been reached. Benefits for PPD are paid over a specified period of time, spending on the severity of the permanent impairment.
Permanent Total Disability (PTD)
An injured worker whose injuries have rendered him permanently unable to perform the kind of work for which he is qualified, and who cannot perform other work that is reasonably available. In most cases, benefits for PTD are paid for the remainder of the injured worker's life.
Physician's First Report of Work Injury (S-1)
A report that a physician files with a workers' compensation carrier after an injured work is examined by the physician, for the first time, after the accident. Also known as Labor Commission Form 123.
Physician Progress Report (PPR form)
State of Nevada approved form that physicians provide injured workers after medical appointment.  This form discusses diagnosis, treatment plan and also whether permanent impairment has been sustained once the injured worker is released from care.
Policies In Force
The total number of policies that are active at a given point in time. Policies In Force is used to calculate claims frequency.
Policy Period
The time period during which a policy is effective or in force.
Policy Year
The year of the inception date of a policy.
Policy Year Experience
The matching of policy year losses with policy year premium. Policy Year Experience changes as losses develop and premium finalizes.
Policy Year Losses
The combined losses on policies with a given policy year. Policy Year Losses for a given year change as claims develop. The ultimate Policy Year Losses is known once all claims that occurred during the given policy year are settled.
Policy Year Premium
The combined premium from policies with a given policy year. Policy Year Premium for a given year changes as premium adjusts in subsequent years. The ultimate Policy Year Premium is known once all premium adjustments are finalized. Policy Year Premium includes the entire premium for a policy in the policy year.
Policyholder Acquisition Costs
The expenses incurred by an insurance company that are directly related to writing a policy.
Policyholder Surplus
The excess of an insurance company's assets above its legal obligations to pay benefits to its policyholders and claimants. The Policyholder Surplus is net worth as stated on the statutory annual blank.
Preferred Provider Organization (PPO)
A formally organized entity consisting of hospitals, physicians, and other healthcare providers. A PPO allows insurance companies to negotiate directly for healthcare services at lower price than would normally be charged. Insurance companies recommend the PPOs they have negotiated with to the insureds.
Premium
The price paid by a policyholder to an insurance company in return for insurance coverage.
Premium Audit
An examination of a policyholder's operations, books and records by a premium specialist to determine the actual insurance exposure for the coverages provided.
Premium Refund
The premium returned to the policyholder, which is the amount of premium that has been collected over and above the final earned premium.
Premium Reserves
1. Premium Earned But Not Received (EBNR) - Premium due but not received by the end of the accounting period. 2. Unearned Premium Reserve (UEPR) - Premium paid for coverage beyond the end of the accounting period.
Premium Specialist (also known as Premium Auditor)
An individual that does premium audits for an insurance company.
Premium Tax
Payment made to a state, or municipally, by an insurance company based on written premium.
Proceeds
Benefits payable under an insurance policy.
Professional Employer Organization (PEO)
A company that provides outsourced insurance benefits and human resource consulting to other companies. The insurance benefits are provided as part of a group policy. Also known as employee leasing.
Prospective Rating
The determining of premium rates based on loss experience over a specified past period of time. The state rates for workers' compensation are prospectively rated based on prior loss experience for the state.
Provider Reimbursement Group (PRG)
The WCF Insurance department that processes medical claim payments.

 

Q
Quasi-Public
WCF Insurance is considered a Quasi-Public corporation. WCF Insurance is owned by its policyholders, yet still serves a public interest since it is required by law to be the carrier of last resort for the state of Utah.

 

R
Recoveries
Amounts received by WCF Insurance as reimbursement from paid losses. Recoveries include amounts from overpayments, subrogation and second injury fund.
Reinsurance
An agreement whereby the reinsurer, for consideration, agrees to compensate the ceding company for all or part of the losses which the ceding company may experience under the policy or policies which it has issued.
Reinsured
An insurance company which has placed reinsurance risk with a reinsurer in the business of buying reinsurance. Also known as ceding company.
Reinsurer
A company that assumes the liability of another by way of reinsurance.
Request for Authorization (RFA)
A California form that the doctor is required to use to request treatment, diagnostic tests or other medical services for an injured worker.
Reserves
Insurance company funds set aside to met future obligations.
Restorative Services Authorization Form (RSA)
A Labor Commission form required for use by any provider (mainly physical therapists and chiropractors) that bill under the restorative services section of the Labor Commission's fee schedule. The form is used to communicate treatment requests to the insurance carrier, and for the carrier to communicate authorization or denial of treatment.
Retrospectively Rated Policy
A policy where the final premium is determined based on a formula using the current policy period's incurred losses. The formula elements and factors are included on the policy. Initially, premium is estimated using expected losses. After policy expiration, the premium is adjusted using actual losses. A Retrospectively Rated Policy is similar to self insurance due to the risk assumed by the policyholder, but unlike self insurance the assumed risk under a Retrospectively Rated Policy is limited.
Return to Work (RTW)
Status typically provided by a physician releasing an injured worker back to light or full duty work.
Risk
1. The individual or organization insured. 2. Uncertainty of financial loss.
Risk Based Capital Requirements (RBC)
The minimum capital standards that an insurance company must meet based on an assessment of the risk associated with the insurance company's operations.
Risk Unit
The intrinsic item insured, e.g. the employee covered by workers' compensation insurance.

 

S
Safety Rule
Some states allow for a reduction in worker’s compensation benefits in the event an injured worker willfully or knowingly violates a company specified safety rule.
Standard Premium
Premium after adjustment for experience modification, safety credits/debits, schedule credits/debits, and association credits, but prior to adjustment for size discount and expense constant. Standard Premium is used in retrospective rating to calculate the basic premium, maximum, and minimum.
Statutory Accounting Principles (SAP)
The rules of accounting and reporting required by state law that must be followed by insurance companies in submitting their financial statements to state insurance departments.
Schedule Credit/Debit
A premium discount, or surcharge, available to policyholders, when manual premium is greater than $10,000. Schedule rating provides up to a 25% discount or surcharge based on the policyholder's workplace safety programs and risk characteristics.
Second Injury Fund
An insurance fund set up by most states that encourage companies to hire workers that have been handicapped by a prior workplace injury. When a worker has a second injury, after being hired by another company, the current company's insurance company is responsible for only the costs of the second injury. The Second Injury Fund will pay the difference between the total costs and the costs of the second injury. Second Injury Funds are usually funded by general state revenues or by assessments on workers' compensation companies. Also known in Utah as the Employers Reinsurance Fund (ERF).
Self Insurance
Protecting against losses by setting aside a company's own money, rather than purchasing an insurance policy. By being self insured, a company saves expenses that an insurance company charges for acquisition, premium tax, and general overhead. Often self insured companies use a third party administrator to administer its claims.
Solvency 
The minimum standard of financial health for an insurance company, where assets exceed liabilities. State laws require insurance regulators to step in when the solvency of an insurance company is threatened and proceed with rehabilitation or liquidation.
Standard Exception
Certain employee groups rated separately instead of being included under the main class code. The Standard Exception, for workers' compensation, are 8810 Clerical Office, 8742 Outside Sales, and 7380 Drivers, unless the main class code description states that one of these employee group are included under the main class code.
Statutory Employee Exclusion Policy
A waiver of insurance coverage, available in Utah, that an independent contractor can purchase as proof to other companies that the contractor has elected to not be covered by workers' compensation insurance. The waiver also excludes the contractor from being covered by another company's policy. These exclusion policies are available for purchase from the Utah Labor Commission for a nominal fee.
Stop Loss Provision
A policy provision on a retrospectively rated policy that limits the loss amount for any individual claim that is included in calculating the retrospective premium. A Stop Loss Provision is an additional election, made by the policyholder, for which they are given a higher basic premium factor.
Subrogation
An insurance company's right to take legal action against a third party responsible for a loss to an insured for which a claim has been paid.
Summary of Payments (SOP)
A form filed in Idaho by the insurance carrier within one hundred twenty days of termination of disability for all time-loss claims upon which the carrier has made payment, except for those claims which are resolved by lump sum settlement.
Supportive Care Award (SCA)
An award of benefits in Arizona for medical treatment after the injured worker is placed at Maximum Medical Improvement (MMI).

 

T
Temporary Partial Disability (TPD)
An injured worker's status prior to reaching maximum medical improvement has been reached, during which he can perform some work, usually in a modified duty capacity or at fewer than normal hours per day. Benefits for TPD are paid until the worker is released to full duty work, or has reached maximum medical improvement.
Temporary Total Disability (TTD)
An injured worker's status prior to reaching maximum medical improvement has been reached, during which he is unable to perform any work, as determined by a physician. Benefits for TTD are paid until the worker is released to return to work, or has reached maximum medical improvement.
Term Payroll Report
A payroll report sent to WCF Insurance by a term policyholder that reports the actual exposure that occurred during the term period. The report is used to calculate final premium.
Term Policy
An insurance policy that is written with an established expiration date. Coverage only continues if the policy is renewed. The policy is written with estimated premium based on estimated payroll exposures. After expiration, a premium audit will gather actual payroll exposures, from which the final premium can be determined. The difference between the estimated premium and the final premium will be either refunded if estimated is greater than final, or billed if final premium is greater than estimated, assuming the estimated premium has been collected.
Terms
The provisions of an insurance policy.
Third Party Administrator (TPA)
The performance of the claims functions related to an insurance plan by a company that is not an original party to the insurance plan. Pinnacle Risk Management Services is a TPA.
Total Incurred Loss
An amount that represents the current expected payout on a claim over the life of the claim. Incurred loss is equal to net paid losses (paid losses less recoveries) plus reserves.
Total Reserves
All reserves on outstanding claims, whether known or unknown. Includes case reserves, IBNR reserves, and bulk reserves. Also includes reserves for loss adjustment expenses.
Trade Association
A group of companies in a similar industry that is organized to obtain cost savings. Each Trade Association generally endorses one insurance company as its workers' compensation insurance carrier of choice in exchange for premium discounts. An association member receives an association credit, or premium discount, if they meet the program's requirements.

The following trade associations each have endorsed WCF Insurance as its workers' compensation insurance carrier of choice: Associated General Contractors (AGC), Utah Manufacturers Association (UMA), Utah Motor Transport Association (UMTA), Utah Roofing Contractors Association (URCA), Utah Home Builders Association (HBA), and Utah Trucking Association (UTA).

Treaty Reinsurance 
The reinsurance of part of the policies written by an insurance company. Treaty Reinsurance may be by participating type, where the insurance company and reinsurer share the risk based on a pro rata share agreement, or by excess type, where the reinsurer reimburses the insurance company for claims that exceed a predetermined loss amount. Compare with facultative reinsurance.

 

U
Ultimate Net Loss
The total payments resulting from a claim over the life of the claim, plus all related expenses, less recoveries and reinsurance. Total payments reflect that the loss has fully developed, and all loss payments are known.
Underwriter
An individual that decides which applicants are accepted or rejected, what coverage is provided, and what price to charge for the coverage.
Underwriting Profit or Loss
An insurance company's profit or loss strictly from its insurance operations, as opposed to investment operations.
Unearned Premium
The portion of the premium applicable to the unexpired period of the policy.
Utilization Review (UR)
The WCF Insurance department that determines the medical necessity of services and procedures that have been submitted as necessary for a claimant.  Some states outside Utah also have utilization review protocols that must be followed when determining medical necessity of certain services and procedures.

 

V
Vocation Rehabilitation (VR)
The WCF Insurancedepartment that promotes early return to work for injured workers.  Other states such as California and Nevada also have vocational rehabilitation benefits that assist an injured worker in retraining for other occupations after an injury.

 

W
Waiver Policy
See Statutory Employee Exclusion Policy
Workers Compensation Appeals Board (WCAB)
The Workers Compensation Appeals Board is the judicial body appointed by the Governor of California and confirmed by the Senate.  It exercises all judicial powers vested in it by the California Labor Code.  Its major functions include review of petitions for reconsideration of decisions by workers compensation administrative law judges of the Division of Workers Compensation and regulation of the adjudication process by adopting rules of practice and procedure.
Workers Compensation Insurance
Insurance coverage for employees required by law in case of injury or death due to an occupational accident, regardless of employer's negligence.
Workers Compensation Unit Report
A statistical report that provides information about payroll, premium and losses for a specific policy and state. Unit Reports are used to calculate e-mods for a policyholder. The Units Reports are submitted to the NCCI, or other rating organizations.
Wrap-up Policy
See Owner Controlled Insurance Program
Written Premium
The entire amount or premium written during a certain period regardless of which portions have and have not been earned.
 

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Insurance coverage in all states other than Utah is provided by Advantage Workers Compensation Insurance Company, a wholly-owned subsidiary of WCF Mutual Insurance Company, doing business as WCF Insurance. Advantage is domiciled in Indiana; NAIC number: 40517. Administrative office: P.O. Box 571918, Salt Lake City, UT 84157-1918.
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