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ISO Report 2022NCCI INC 901 PENINSULA CORPORATE CIRCLE BOCA RATON FL 33487-1362 6/13/2022 CONFIDENTIAL BLAIR CITY OF 218 S 16TH ST BLAIR NE 68008-2010 Dear Madam or Sir: Your experience rating worksheet is now available for rating effective date 11/1/2022. Please log on to our website with the following information: Launch your web browser. Enter https://worksheets.ncci.com &? Worksheets On Demand Service X + F -'- 0 https://worksheets.ncci.com Once in Worksheets On Demand Service (WSD) enter your Risk ID: 260110098 Risk ID _ i Next enter your PIN: 2F5K5bss (characters are case sensitive) Pin _...._... Read and Accept the Disclaimer Read and Accepted the Disclaimer I -1 For the last step, click "Log In" to gain access to the website. You can access your experience ratings electronically, as well as provide your email address for notification of experience rating revisions. The National Council on Compensation Insurance, Inc. (NCCI) is the nation's largest information company serving the workers compensation marketplace. Our services include the calculation of your workers compensation experience rating. For a detailed explanation of experience rating and how it is calculated, please select the Experience Rating education links on the left side of the website. Should you have any questions regarding this letter, please call our Customer Service Center at 800-NCCI-123 (800-622-4123) and select the Experience Rating option, or email our Customer Service Center at customer service@ncci.com. Sincerely, Experience Rating Department 434 WORKERS COMPENSATION EXPERIENCE RATING cc,f Risk Name: BLAIR CITY OF Risk ID: 260110098 a Rating Effective Date: 11/01/2022 Production Date: 06/13/2022 State: NEBRASKA State Wt Exp Excess Expected Exp Prim Act Exc Losses Ballast Act Inc Losses Act Prim Losses Losses Losses I I I I Losses NE .131 95,08d 142,497 47,4091 93,2971 39,550 154,439 61,142 (A) (B) 7C) Exp Excess (D) Expected (E) Exp Prim (F) Act Exc (G) Ballast (H) Act Inc (1) Act Prim Wt i Losses (D - E) Losses I Losses Losses (H -1) Losses Losses 1.131 1 95,0881 142,4971 47,4091 93,2971 39,5501 150,4901 57,1931 Primary Losses Stabilizing Value Ratable Excess Totals (I) C * (1 - A) + G (A) * (F) (J) Actual 57,193 122,277 12,129 191,599 (E) C-(1 - A) + G (A) * (C) (K) Expected 47,409 122,277 12,361 182,047 ARAP FLARAP SARAP MAARAPExp Mod (J) / (K) Factors 1.05 RATING REFLECTS A DECREASE OF 70% MEDICAL ONLY PRIMARY AND EXCESS LOSS DOLLARS WHERE ERA IS APPLIED. © Copyright 1993-2022, All rights reserved. This product is comprised of compilations and information which are the proprietary and exclusive property of the National Council on Compensation Insurance, Inc. (NCCI). No fudher use, dissemination, sale, transfer, assignment or disposition of this product, in whole or in part, may be made without the prior written consent of NCCI. This product is furnished °As is' 'As available' With all defects' and includes information available at the time of publication only. NCCI makes no representations or warranties of any kind relating to the product and hereby expressly disclaims any and all express, statutory, or implied warranties, including the implied warranty of merchantability, fitness fora particular purpose, accuracy, completeness, currentness, or correctness of the product or information contained therein. This product and the information contained therein are to be used exclusively for underwriting, premium calculation and other Insurance purposes and may not be used for any other purpose including but not limited to safety scoring for project bidding purposes. All responsibility for the use of and for any and all results derived or obtained through the use of the product and information are the end user's and NCCI shall not have any liability thereto. Page 1 of 3 WORKERS COMPENSATION EXPERIENCE RATING 11VEW1 Risk Name: BLAIR CITY OF Risk ID: 260110098 Rating Effective Date: 11/01/2022 Production Date: 06/13/2022 State: NEBRASKA 26 -NEBRASKA Firm ID: Firm Name: BLAIR CITY OF Carrier: 12211 Policv No. CIWC929620 Eff Date: 11/01/2018 Exp Date: 11/01/2019 Code ELR D- Ratio Payroll Expected 11 Losses Exp Prim Losses Claim Data IJ OF Act Inc Act Prim Losses Losses 5506 2.81 .28 354,588 9,964 2,790 55097896 05 F 77,612 18,500 7520 2.18 .37 418,609 9,126 3,377 NO.7 06 4,733 4,733 7580 1.31 .32 238,541 3,125 1,000 7711 2.74 .28 15,300 419 117 7720 1.48 .32 1,088,499 16,110 5,155 8810 .08 .39 947,792 758 296 8831 .65 .44 21,727 141 62 9015 1.51 .37 119,894 1,810 670 9220 2.16 .37 211,526 4,569 1,691 9807 EMPLOYERS LIABILIT 0 0 Policy Total: 3,416,47 Subject Premium: 106,990 JTotal Act Inc Losses: 82,345 26 -NEBRASKA Firm ID: Firm Name: BLAIR CITY OF Carrier: 12211 Policv No. CIWC036256 Eff Date: 11/01/2019 Exp Date: 11/01/2020 Code ELR D- Ratio 5506 2.81 .28 Payroll 339,812 Expected Losses 9,549 Exp Prim Losses 2,674 Claim Data 55110895 IJ OF Act Inc Act Prim Losses Losses 05 F 29,994 18,500 7520 2.18 .37 646,884 14,102 5,218 NO.3 06 909 909 7580 1.31 .32 245,145 3,211 1,028 7705 2.36 .37 3,3001 78 29 7711 2.74 .28 11,700 321 90 7720 1.48 .32 1,144,150 16,933 5,419 8810 .08 .39 958,696 767 299 8831 .65 .44 23,362 152 67 9102 1.54 .37 197,694 3,044 1,126 9410 1.47 .391 138,611 2,038 795 9807 EMPLOYERS LIABILIT 01 0 Policy Total: 3,709,354,Premium. Subject 112,408 Total Act Inc Losses: 30,903 Copyright 1993-2022, All rights reserved. This product is comprised of compilations and information which are the proprietary and exclusive property of the National Council on Compensation Insurance, c. (NCCI). No further use, dissemination, sale, transfer, assignment or disposition of this product, in whole or in part, may be made without the prior written consent of NCCI. This product is furnished 'As is 4s available' With all defects' and includes information available at the time of publication only. NCCI makes no representations or warranties of any kind relating to the product and hereby expressly isclaims any and all express, statutory, or implied warranties, including the implied warranty of merchantability, fitness for a particular purpose, accuracy, completeness, currentness, or correctness of the roduct or information contained therein. This product and the information contained therein are to be used exclusively for underwriting, premium calculation and other Insurance purposes and may not be sed for any other purpose including but not limited to safety scoring for project bidding purposes. All responsibility for the use of and for any and all results derived or obtained through the use of the produc no information are the end users and NCCI shall not have any liability thereto. Total by Policv Year of all cases $2000 or less. D Disease Loss X Ex -Medical Coverage U USL&HW C Catastrophic Loss E Employers Liability Loss # Limited Loss Page 2 of 3 WORKERS COMPENSATION EXPERIENCE RATING /i/CC/ Risk Name: BLAIR CITY OF Risk ID: 260110098 Rating Effective Date: 11/01/2022 Production Date: 06/13/2022 State: NEBRASKA 26 -NEBRASKA Firm ID: Firm Name: BLAIR CITY OF Carrier: 12211 Policv No. CIWC143395 Eff Date: 11/01/2020 Exp Date: 11/01/2021 Code ELR s D- Ratio Payroll Expected Losses Exp Prim Losses Claim Data i IJ OF Act Inc Act Prim Losses Losses 5506 2.81 .28 314,166 8,828 2,472 55127891 05 F 41,191 18,500 7520 2.18 .37 598,981 13,058 4,831 7580 1.31 .32 205,900 2,697 863 7720 1.48 .32 1,036,004 15,333 4,907 8810 .08 .39 1,131,567 905 353 8831 .65 .44 25,113 163 72 9102 1.54 .37 173,496 2,672 989 9220 1 2.16 .371 9,386 203 75 9410 1 1.47 .39 164,665 2,421 944 9807 EMPLOYERS LIABILIT 0 0 Subject Policy Total: 3,659,27 Premium: 100,759 Total Act Inc Losses: 41,191 Copyright 1993-2022, All rights reserved. This product is comprised of compilations and Information which are the proprietary and exclusive property of the National Council on Compensation Insurance, to. (NCCI). No further use, dissemination, sale, transfer, assignment or disposition of this product, In whole or in part, maybe made without the prior written consent of NCCL This product is furnished `As is 1s available' °With all defects' and includes information available at the time of publication only. NCCI makes no representations or warranties of any kind relating to the product and hereby expressly Isclaims any and all express, statutory, or implied warranties, including the implied warranty of merchantability, fitness for a particular purpose, accuracy, completeness, currentness, or correctness of the roduct or information contained therein. This product and the Information contained therein are to be used exclusively for underwriting, premium calculation and other Insurance purposes and may not be sed for any other purpose including but not limited to safety scoring for project bidding purposes. All responsibility for the use of and for any and all results derived or obtained through the use of the produc nd information are the end user's and NCCI shall not have any liability thereto. Total by Pnlir.v Year of all cases $2000 or less. D Disease Loss X Ex -Medical Coverage U USL&HW C Catastrophic Loss E Employers Liability Loss # Limited Loss Page 3 of 3