| Effective Date | The desired coverage effective date. |
| FEIN | (Optional) – Federal Employer Identification Number. Used with effective date to determine experience/merit modification. |
| Employer Name | Used for identification purposes on the printed report. |
| Experience Modification | If the current experience/merit modification effective date differs more than 3 months from the desired coverage effective date no modification factor will populate. You may call Customer Service at 734-462-9600 for assistance. |
| Press to clear the form and start over. | |
| Print or save the report for distribution. | |
| View the class code lookup tool. | |
| Redirect to the Online Assigned Risk (OAR) application. |
The premium estimate is based on the class code and payroll information provided. The experience modification and surcharge shown, if any, are tentative factors based on information in CAOM’s system for this FEIN and requested coverage effective date. Changes in modification effective date could result in a recalculation of the modification/surcharge factors.
| Class Code | Description | USLHW | No of Employees |
Total Payroll | Rate | Premium |
|---|
| Manual Premium: | ||
| Increased Limits: | ||
| Experience Modification: | ||
| Standard Premium: | ||
| Premium Discount: | ||
| Expense Constant: | ||
| Plan A Surcharge: | ||
| Terrorism (Payroll ÷ 100 X .01) | ||
| Total Estimated Premium: | ||
| Deposit Premium Percent: | ||
| Your Deposit Premium: |