EMOD Calculation FormSpecial District Risk Management Authority
Workers' Compensation Program
Program Year 2021-22
Experience Modification (EMOD) Calculation Form
Costa Mesa Sanitary District
290 Paularino Avenue
Costa Mesa, California 92626
SummaryPY 2021-22 EMOD -
PY 2020-21 EMOD -
167%
122%
Detail Calculations for Program Year 2021-22
Expected Losses
Class
Codes
Total
Payroll
Expected
Loss Rate
Expected
Primary Losses
2017-18 Payroll2018-19 Payroll2019-20 Payroll Expected
Excess Losses
Total Expected
Losses
7580 $450,238 $454,242 $500,987 $1,405,467 0.0128 $14,499.93$3,490.05$17,989.98
8742-D $0 $94,891 $94,047 $188,938 0.0017 $242.18$79.01$321.19
8742-M $112,395 $20,839 $20,746 $153,980 0.0017 $197.37$64.40$261.77
8742-P $0 $0 $0 $0 0.0017 $0.00$0.00$0.00
8810 $491,101 $448,279 $365,954 $1,305,334 0.0012 $1,132.50$433.89$1,566.39
9015 $31,382 $31,609 $39,920 $102,911 0.0218 $1,702.79$540.68$2,243.47
9410 $156,907 $211,080 $353,342 $721,329 0.0065 $3,267.98$1,420.66$4,688.64
$21,042.75$6,028.69$27,071.44$1,242,023 $1,260,940 $1,374,996 $3,877,959
Actual Losses valued as of 12/31/2020
Actual Losses*Actual Excess LossesActual Primary LossesClaims CountYear Actual Incurred Losses
2
1
3
$904.34
$13,923.99
$18,627.50
$3,673.99
$4,236.93
$404.34
$10,000.00
$13,640.57
2017-18
2018-19
2019-20
$404.34
$13,673.99
$17,877.50
$0.00
$7,910.92$24,044.91* Actual Losses are capped at $175,000 per claim for purposes of EMOD calculations.Totals $31,955.83
EMOD Calculation - Based on Workers' Compensation Insurance Rating Bureau's (WCIRB) rating model.
Total Adjusted Losses
/Total Expected
Losses =
$27,071.44 167%
2021-22 EMODExpected Excess
Losses
Actual Primary
Losses
(+$24,044.91 )$21,042.75
Special District Risk Management Authority
1112 I Street Suite 300, Sacramento, California 95814-2865
Tel 916.231.4141 or 800.537.7790 Fax 916.231.4111
www.sdrma.org
Printed 3/26/2021
Special District Risk Management Authority
Workers' Compensation EMOD Claims Detail
Program Year 2021-22
Costa Mesa Sanitary District
*ActualTotal Injury
Status CategoryNumberDate Losses IncurredType
Claim InjuryClaimInjury
01/17/2018 SDWA-559322 First Aid Struck - Animal/Insect $353.44 $103.44C
03/20/2018 SDWA-559457 First Aid Struck - Animal/Insect $550.90 $300.90C
2017-18 No. of Claims 2 $904.34 $404.34
02/14/2019 SDWA-560171 Indemnity Injury - Pushing/Pulling $13,923.99 $13,673.99C
2018-19 No. of Claims 1 $13,923.99 $13,673.99
09/05/2019 SDWA-560675 Indemnity Slip/Fall - Different Level $14,486.93 $14,236.93C
10/10/2019 SDWA-560748 Medical Injury - Pushing/Pulling $1,590.57 $1,340.57C
06/09/2020 SDWA-561194 Medical Cut/Punct/Scrap $2,550.00 $2,300.00O
2019-20 No. of Claims 3 $18,627.50 $17,877.50
No. of Claims 6 $31,955.83$33,455.83Total
* Actual Losses have the first $250 excluded and are capped at $175,000
Special District Risk Management Authority
1112 I Street Suite 300, Sacramento, California 95814-2865
Tel 916.231.4141 or 800.537.7790 Fax 916.231.4111
www.sdrma.org
Printed 3/26/2021