Les Form Si-17 - Unit Statistical Report (New Applicant) (Page 3 of 4) in pdf

DEFINITIONS

ALLOCATED LOSS ADJUSTMENT EXPENSE

Expenses such as attorney's fee, legal expense, investigation costs, witness fees, court costs, documents cost and other

expenses directly related and allocated to the cost of settling a specific claim. DO NOT include unallocated loss

adjustment expenses, i.e., expenses which are not directly assignable to a particular claim.

DATE OF ACCIDENT

Accident dates for injuries on a given report shall fall between the beginning and ending dates of the specific report, even

if the accident date of the injury is not reported (i.e., non-excess claims).

EXCESS CLAIM: (Ref. Pg. 17 WCSP)*

Claim where the total incurred loss is greater than $5,000.00.

INCURRED LOSS: (Ref. Pg. 60, WCSP)*

The total dollar amount which the self-insurer expects to pay to the conclusion of the case and includes both payments

already made and outstanding reserves. Incurred losses shall exclude attorney fees awarded due to "bad faith" on the

part of the self-insurer, pursuant to Section 440.34, Florida Statutes.

INDEMNITY: (Ref. Pg. 17 WCSP)*

Vocational rehabilitation cost and outstanding reserves for future compensation payments shall be included as part of the

amount reported for indemnity.

MEDICAL ON ALL COMPENSABLE CLAIMS: (Ref. Pg. 25 WCSP)*

Opposite each type of compensable claim, enter the medical cost (paid plus outstanding reserves) in connection with

such claim. Include all payments to doctors and hospitals as well as physical rehabilitation but do not include any claims

expense.

NCCI INJURY CODE: Indicates the kind of injury. (Ref. Pg. 62c WCSP and Pg. 18 & 19 WCSP)*

DEATH:

(code #1) Amount entered as indemnity shall include all paid and outstanding benefits including

compensation paid to the deceased prior to death; include burial expenses.

PERMANENT TOTAL DISABILITY: (code #2) Enter any claim which has been adjudged permanent total or

which is defined under law as permanent total or which, in the self-insurer's judgment, will result in permanent

total disability.

UNIT STATISTICAL PLAN may be obtained through the National Council on Compensation Insurance, Boca

Raton, Florida.

WAGE LOSS & NO IMPAIRMENT BENEFIT: (code #3) Enter every case where wage loss benefits are paid or

payable under Section 440.15(3), Florida Statutes, and no impairment benefit is paid or payable. The amount

entered as indemnity shall include compensation for temporary disability.

WAGE LOSS & IMPAIRMENT BENEFIT: (code #4) Enter every case where both wage loss and impairment

benefits are paid or payable under Section 440.15(3), Florida Statutes. Include compensation for temporary total

disability. The amount entered as indemnity shall include compensation for temporary disability.

TEMPORARY TOTAL OR TEMPORARY PARTIAL BENEFITS: (code #5) Enter every case which involves or is

expected to involve indemnity benefits but which do not constitute a case of death, permanent total, wage loss or

impairment benefits.

MEDICAL ONLY CLAIMS: (code #6) Enter zero (0) under indemnity and use code #6.

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

Page 3 of 4

Les Form Si-17 - Unit Statistical Report (New Applicant) Page 3