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The Premier Solution, helping employers negotiate the best
Workers Compensation rates and services.

The Premier Solution, helping employers negotiate the best
Workers Compensation rates and services

Wondering what your next renewal will cost you? Project your premium!

Step 1 of 4

25%

Use Our Premium Calculator
Class Codes & payroll info*
In order to project your net rates for your upcoming renewal we need the following information which can be found on your POLICY DECLARATION PAGE. IF you do not have your policy declaration page you can request one from your carrier, but it should be included.

Class Code – This should be located in your policy, on your current “Declaration Page”.

Description – Enter a description of the class code shown on your current “Declaration Page”.

Carrier Rate – The carrier rate is located in your policy on your current “Declaration Page”. DO NOT ENTER NET RATES.

Est. Payroll LY – Enter LAST YEARS estimated Payroll number for the class code. This is shown on your current “Declaration Page”.

Est. Payroll TY – Enter next years estimated Payroll number for this class code.
Class Code Description Carrier Rate Est. Payroll LY Est. Payroll TY
Use the + sign to the right of the last field to add additional lines as needed

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
Name
This field is for validation purposes and should be left unchanged.

The Premier Solution, helping employers negotiate the best
Workers Compensation rates and services.

The Premier Solution, helping employers negotiate the best
Workers Compensation rates and services

Wondering what your next renewal will cost you? Project your premium!

Wondering what your next renewal will cost you? Project your premium!

Step 1 of 4

Use Our Premium Calculator

In order to project your net rates for your upcoming renewal we need the following information which can be found on your POLICY DECLARATION PAGE. IF you do not have your policy declaration page you can request one from your carrier, but it should be included.

Class Code – This should be located in your policy, on your current “Declaration Page”.

Description – Enter a description of the class code shown on your current “Declaration Page”.

Carrier Rate – The carrier rate is located in your policy on your current “Declaration Page”. DO NOT ENTER NET RATES.

Est. Payroll LY – Enter LAST YEARS estimated Payroll number for the class code. This is shown on your current “Declaration Page”.

Est. Payroll TY – Enter next years estimated Payroll number for this class code.

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

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.

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)

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.

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

Contact Info

If you need help with this form, email us at info@compsure.net

Class Code	Description	Carrier Rate	Est. Payroll LY	Est. Payroll TY

The Premier Solution, helping employers negotiate the best Workers Compensation rates and services.

The Premier Solution, helping employers negotiate the best Workers Compensation rates and services

Wondering what your next renewal will cost you? Project your premium!

Wondering what your next renewal will cost you? Project your premium!

Step 1 of 4

Use Our Premium Calculator

In order to project your net rates for your upcoming renewal we need the following information which can be found on your POLICY DECLARATION PAGE. IF you do not have your policy declaration page you can request one from your carrier, but it should be included.

Class Code – This should be located in your policy, on your current “Declaration Page”.

Description – Enter a description of the class code shown on your current “Declaration Page”.

Carrier Rate – The carrier rate is located in your policy on your current “Declaration Page”. DO NOT ENTER NET RATES.

Est. Payroll LY – Enter LAST YEARS estimated Payroll number for the class code. This is shown on your current “Declaration Page”.

Est. Payroll TY – Enter next years estimated Payroll number for this class code.

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

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.

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)

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.

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

Contact Info

If you need help with this form, email us at info@compsure.net

The Premier Solution, helping employers negotiate the best
Workers Compensation rates and services.

The Premier Solution, helping employers negotiate the best
Workers Compensation rates and services