Take Control of Your Workers Comp | CompSure Insurance Solutions

25%

XMOD
ENTER your current EXPIRING XMOD from your declaration page. Your xmod should be entered as a decimal number not a percentage. For example, if your XMOD is 120% enter it as 1.20 if it is 79% enter it as .79.
Expiring XMOD*
This should be located in your policy, on your your current "Declaration Page".
New XMOD*
If you have it, enter it here. If not, just enter the number 1

Credits & Debits
ENTER all schedule Credits (that reduce your cost) and Debts (that add to your cost) in the same sequence as they are listed on your declaration page and enter all values as a positive number (EXAMPLE -12,565 would be entered as 12,565)
Credits & Debits*
Type - Enter the word "Credit or Debit"

Description - Enter a description for the credit or debit

Value - Enter a dollar value for the credit or debit above. All numbers should be entered as positive numbers, even if they are for a debit.

Type Credit or Debit Description $ Value
Use the + sign to the right of the "Value" field to add additional lines as needed

Contact Info
Your Projected Net rates and Benchmark will be calculated. To ensure your privacy we will email the Net Rates and Benchmark to you. Please provide the following information so we can provide your projected Net rates.
Company Name
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email
Phone
Email
This field is for validation purposes and should be left unchanged.

Use the + sign to the right of the last field to add additional lines as needed