Les Form Si-17 - Unit Statistical Report (New Applicant) (Page 2 of 4) in pdf

Les Form Si-17 - Unit Statistical Report (New Applicant) Page 2

INSTRUCTIONS FOR COMPLETING THE

SELF-INSURANCE UNIT STATISTICAL REPORT

(LES FORM SI-17)

General Instructions

This report will be mailed to you on the 20th of the month before your evaluation date. It is due in our office two months

after the evaluation date. Report all injuries with dates of accident between the beginning and ending dates for the report

(inclusive). All information entered on the form must be legible (preferably typewritten).

Specific Instructions

Please refer to the corresponding numbers on the sample form attached. Definitions of key terms are attached to these

instructions.

(1) - (6) These items are completed by the Bureau prior to mailing.

(7)

Indicate the number of pages in the report.

(8)

Enter the social security number of the claimant for an excess claim (over $5,000). Enter the number of

claims in a group of non-excess claims ($5,000 or less). Non-excess claims must be grouped by injury code,

payroll classification code, and status.

(9)

Indicate the status of the claims(s). Enter "0" (zero) for open claims and "1" (one) for closed claims.

(10)

Enter the appropriate NCCI injury code. (Ref. Pg. 3 & 4)

(11)

Enter the appropriate payroll classification code. Do not use classification codes that are not included in your

payroll reports, as you cannot have a claim in a code that has no reported payroll.

(12)

For excess claims only, enter the date of accident. Use the following format: 01/01/97 or 01-01-97.

(13)

Enter the incurred medical cost. Use whole dollars only. (no cents)

(14)

Enter the incurred indemnity cost. Use whole dollars only. (no cents)

(15)

Enter the total incurred medical and incurred indemnity. If your report is more than one page, enter the totals

only on the last page.

(16)

Enter the total allocated loss adjustment expense incurred during the reporting period. If the report is more

than one page, enter the total on the last page only.

NOTE: Failure to comply with the above specific instructions will result in an unacceptable report.

LES Form SI-17 New Applicant (09/96)

Page 2 of 4

Les Form Si-17 - Unit Statistical Report (New Applicant) Page 2