Form NY115 Report Due by: April 01, 2010 NEW YORK

Form NY115
Report Due by: April 01, 2010
NEW YORK COMPENSATION INSURANCE RATING BOARD
CARRIER(S):*
SUBMITTED BY:
TELEPHONE NO:
TITLE:
DATE SUBMITTED:
Re: Annual Call for Direct Written Premium for Calendar Year 2009
Workers Compensation and Employers Liability Insurance New York
The total direct written premium for Workers Compensation and Employers Liability Insurance on risks in New York State during calendar year 2009 for
this carrier were as follows:
[1] Workers Comp
[2] Premium Adj
[3] Premium Adj
[4] Premium Adj
[5] Premium Adj
[6] Premium Adj
[7] Excess Workers
[8] Total
Direct Written
Conv Dir Wrtn Prem
Conv Dir Wrtn Prem
Conv Dir Wrtn Prem
Conv Dir Wrtn Prem
Conv Dir Wrtn Prem
Compensation
Standard Written
PremiumNew
Line 16York
Workers Compensation and Employers Liability Insurance
Column 1, Page 14
Company Names:
Policies Subj to
Policies Subj to
Policies Subj to
Policies Subj to
Policies Subj to
Premium
Retro Rating Plan
Premium Discount
Rate Deviation
Deductible
Safety Program
1+2+3+4+5+6-7
Act to Std Basis
Act to Std Basis
Act to Std Basis
Act to Std Basis
Act to Std Basis
Printed 12/23/2009 4:21 PM
Form NY115
Report Due by: April 01, 2010
NEW YORK COMPENSATION INSURANCE RATING BOARD
CARRIER(S):*
SUBMITTED BY:
TELEPHONE NO:
TITLE:
DATE SUBMITTED:
Re: Annual Call for Direct Written Premium for Calendar Year 2009
Workers Compensation and Employers Liability Insurance New York
The total direct written premium for Workers Compensation and Employers Liability Insurance on risks in New York State during calendar year 2009 for
this carrier were as follows:
[1] Workers Comp
[2] Premium Adj
[3] Premium Adj
[4] Premium Adj
[5] Premium Adj
[6] Premium Adj
[7] Excess Workers
[8] Total
Direct Written
Conv Dir Wrtn Prem
Conv Dir Wrtn Prem
Conv Dir Wrtn Prem
Conv Dir Wrtn Prem
Conv Dir Wrtn Prem
Compensation
Standard Written
PremiumNew
Line 16York
Workers Compensation and Employers Liability Insurance
Column 1, Page 14
Company Names:
Policies Subj to
Policies Subj to
Policies Subj to
Policies Subj to
Policies Subj to
Premium
Retro Rating Plan
Premium Discount
Rate Deviation
Deductible
Safety Program
1+2+3+4+5+6-7
Act to Std Basis
Act to Std Basis
Act to Std Basis
Act to Std Basis
Act to Std Basis
Printed 12/23/2009 4:21 PM