Your Name (required)

Your Email (required)

Phone Number

Company Name

Mod effective date

Select a single state, or "Multi" for multiple-state computation:
MultiAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Box A: W value

Box C: Expected excess losses

Box D: Total expected losses

Box E: Total expected primary losses

Box F: Actual excess losses

Box G: Ballest value

Box H: Total actual losses

Box I: Actual primary losses

Estimated manual premium