For employers in every industry

Know what’s behind your experience mod.

Request a copy of your most recent available workers’ compensation experience modification worksheet.

Please allow 24 hours. A person will review your request and follow up by email. If the worksheet is unavailable or additional authorization is needed, we will explain the next step.

What is an Ex-Mod worksheet?

An experience modification worksheet shows the payroll, classification, and loss information used by the rating bureau to calculate an employer’s experience modification factor, also called an Ex-Mod, X-Mod, or EMR. This factor can affect workers’ compensation premium.

It can help you understand the number, identify information to review with your agent, or prepare for a renewal or contract conversation. Not every employer has a worksheet. Availability, the applicable bureau, and any additional authorization must be confirmed.

This is different from a coverage search, which helps identify insurance coverage. Our team handles worksheet requests personally.

NCCI: ABCs of Experience Rating →

Your existing agent can stay involved. Requesting a worksheet does not appoint or replace an agent.

Request my worksheet

Required fields are marked *. No mobile number is needed.

Your name *Email for follow-up *

Employer informationLegal business name *Use the employer’s name as shown on its workers’ compensation policy.Business street address *City *

State *ZIP code *

Workers’ compensation policyCurrent coverage *Existing agent or agency, optionalYour request does not change this relationship.USDOT number, if applicableThis helps our team match a trucking request to its DOT report. We will verify the match.

I confirm the employer’s legal name, address, and coverage information are correct. *I am authorized to request this worksheet for the employer named above. I request assistance obtaining its most recent available experience modification worksheet and agree to email follow-up about this request. This does not change our agent or enroll us in marketing. *

Please allow 24 hours for human review and email follow-up. Do not send payroll records, claim details, or your worksheet through public chat.