Indemnity Data Call Forms

Posted Date: November 27, 2018
    

The reporting of the Indemnity Data Call is applicable only to affiliate group participants. Following are the forms related to the Indemnity Data Call.

Click on the links below to download a fillable copy of each form.

Indemnity Data Call—Reporting Contact Form (PDF)

Each Indemnity Data Call affiliate group participant is required to identify a primary reporting contact for its NCCI Group Code. NCCI will work with this contact on a going-forward basis. The form must be completed by NCCI’s affiliate and not by a service provider, such as a third party administrator (TPA).

For affiliate groups that have multiple NCCI Group Codes, a data reporting contact may be designated for each NCCI Group Code or for more than one NCCI Group Code. Separate contact forms are required for each reporting contact.

Business Exclusion Request Form (PDF)

It is expected that 100% of indemnity claims data in applicable states will be reported in the Indemnity Data Call. NCCI does recognize that in certain limited circumstances it can be very difficult, if not impossible, for participants (affiliate groups) to comply with reporting 100% of the expected indemnity claims data.

Accordingly, an affiliate group participating in the Call may exclude from its reporting requirements data for claims that represent up to 15% of gross premium (direct premium gross of deductibles) for all states combined. This option may be utilized for small subsidiaries and/or business segments (e.g., coverage providers, branches, and TPAs) where it may be more difficult to establish the required reporting infrastructure. The exclusion option must be based on a business segment, not claim type or characteristics. All requests for such exclusions must be presented to NCCI for acceptance.

Refer to Part 2—General Rules and Part 11—Forms of the Indemnity Data Call Implementation Guide for additional Business Exclusion Request information.

Business Exclusion Premium Verification Worksheet—Method 1 (PDF)

Use this worksheet to determine if proposed exclusions are less than or equal to 15% of the group’s total written premium when using Premium Determination Method 1. Only include premium from the states where the Indemnity Data Call applies.

Refer to Part 2—General Rules and Part 11—Forms of the Indemnity Data Call Implementation Guide for additional Business Exclusion Request information.

Business Exclusion Premium Verification Worksheet—Method 2 (PDF)

Use this worksheet to determine if proposed exclusions are less than or equal to 15% of the group’s total written premium when using Premium Determination Method 2. This method is an option for affiliate groups with Large Deductible Direct Premium greater than 0.3% of their total premium (NAIC Direct Premiums). Only include premium from the states where the Indemnity Data Call applies.

Refer to Part 2—General Rules and Part 11—Forms of the Indemnity Data Call Implementation Guide for additional Business Exclusion Request information.

Business Exclusion Premium Verification Worksheet—Method 3 (PDF)

Use this worksheet to determine if proposed exclusions are less than or equal to 15% of the group’s total written premium when using Premium Determination Method 3. This method is an option for affiliate groups with Large Deductible Direct Premium greater than 0.3% of their total premium (NAIC Direct Premiums). Only include premium from the states where the Indemnity Data Call applies.

Refer to Part 2—General Rules and Part 11—Forms of the Indemnity Data Call Implementation Guide for additional Business Exclusion Request information.

Business Exclusion Premium Verification Worksheet—Method 4 (PDF)

Use this worksheet to determine if proposed exclusions are less than or equal to 15% of the group’s total written premium when using Premium Determination Method 4. This method is based on Unit Statistical data (gross of deductibles), as reported in the Premium Amount field of the Exposure Record for the most recent 12 months of reported data. Only include premium from the states where the Indemnity Data Call applies.

Refer to Part 2—General Rules and Part 11—Forms of the Indemnity Data Call Implementation Guide for additional Business Exclusion Request information.

Data Provider Profile Form (PDF)

The Indemnity Data Provider Profile form identifies the carrier codes and specific users that will submit data files and must be completed by the carrier. If a third party administrator (TPA), managing general agent (MGA), or vendor (also known as a service provider) is reporting on a carrier’s behalf, the Service Provider Attachment and Service Provider Data Tool Addendum are also required.

Refer to Part 2 B.—NCCI Setup Forms of the Electronic Transmission User’s Guide for additional information

Secure FTP Preinstallation Questionnaire (PDF)

The questionnaire identifies the data provider system setup for automatically transmitting and receiving data files through Data Transfer via the Internet (DTVI).

Refer to Part 2 A.—Data Transmission Options of the Electronic Transmission User’s Guide for additional information.