MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS’ COMPENSATION PROPOSED 2009 RATES FOR WORKERS’ COMPENSATION INSURANCE GROUP SELF-INSURANCE This form is to be filed with the Division of Workers’ Compensation no later than December 15, 2008. Along with this information, please include the actuarial evaluation that substantiates your expected losses. The Division of Workers’ Compensation is not a ratemaking authority, but this information is required for our records. Do not substitute this form. Group Name Third Party Administrator Chairman Account Manager Term Filing METHOD USED TO DEVELOP RATES (Check One) 1. NCCI untrended loss cost data 4. MDI trended loss cost data 2. NCCI trended loss cost data 5. Group loss cost data, actuarially developed 3. MDI untrended loss cost data 6. Other PREMIUM SUMMARY BY CLASSIFICATION Code Description Projected Payroll Rate Estimated Manual Premium 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Totals WC-127 (12-07) AI American LegalNet, Inc. www.FormsWorkflow.com PROJECTED REVENUES & EXPENSES Revenues Premium $ Interest $ Total Revenue $ Expenses Expected Losses $ Administrative Expenses $ Claims $ Excess Insurance $ Directors & Officers Insurance $ Loss Control $ Surety Bond $ Fidelity Bond $ CPA Audit & Tax Return $ Actuarial Evaluation $ Accounting Fees $ Legal Fees $ All taxes including second injury surcharge $ Miscellaneous $ Total Expenses $ Loss Contingency/Surplus (Total Revenue – Total Expenses) $ DISCOUNT SCHEDULE Describe the method developed by the trust to determine appropriate discounts for individual members. Discounts should not exceed 25%, and the basis for discounts must be quantifiable with uniform pricing and application. WC-127-2 (12-07) AI American LegalNet, Inc. www.FormsWorkflow.com