Loss Cost Multiplier Filing Forms

Carriers wishing to establish or revise a loss cost multiplier for use in writing Pennsylvania workers compensation insurance are required to file their proposed multiplier, together with certain specified supporting information, with the Pennsylvania Insurance Department. The Insurance Department requires use of standard forms in supplying the required supporting information for such carrier filings.

Download Form
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The Excel spreadsheet file presented below is the Insurance Department’s required loss cost multiplier forms. Click on the link to download the file. 

Carriers are strongly encouraged to prepare their loss cost multiplier filing(s) using this spreadsheet file.

PENNSYLVANIA FILING FORMS FOR LOSS COST MULTIPLIER