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

CONTRACT MEDICAL: (code #7) Contract medical costs which cannot be allocated to individual claims shall be

reported in the aggregate in the "Medical" column. Enter zero (0) under indemnity and use code #7. Such

medical shall be assigned to the governing payroll class code. Contract medical cost allocated to the individual

claims shall be reported in connection with these claims and shall not be coded "7". Amounts reported shall be

the actual cost incurred.

IMPAIRMENT BENEFIT & NO WAGE LOSS BENEFIT: (code #9) Enter every case where impairment benefits

are paid or payable and no wage loss benefits are paid or payable under Section 440.15(3), Florida Statutes.

HOSPITAL ALLOWANCE: Not applicable to self-insurers.

MEDICAL OR LEGAL EXPENSE: Medical or legal expense incurred for the benefit of the self-insurer to secure

evidence before a Deputy Commissioner or court shall be treated as adjusting expenses. NOTE: Where the

claimant calls the attending physician to give medical testimony on his behalf or where the self-insurer is

required to produce the claimant's physician at the hearing and is required to pay such a physician's fee, the

payment of the fee shall be reported as a medical loss. When an award to a claimant includes the cost of

witness fees, attorney's fees (other than "bad faith") and other court costs, the amount so awarded shall be

included as part of the indemnity benefit.

NON-EXCESS CLAIMS

All claims other than excess claims.

OUTSTANDING RESERVES

Incurred loss less amounts paid as of a specified date. Also known as reserves.

PAYROLL CLASSIFICATION CODE:

Use the code to which the claim has been assigned. Report the code corresponding to the classification determined

according to the NCCI rules and reported to the Bureau of Self-Insurance on LES Form BSI-5. No claims may be

assigned to any classification unless payroll has been reported for than class.

PHYSICAL REHABILITATION (MEDICAL)

Medical or other treatment provided under the direct supervision or instruction of a physician for the purpose of restoring

or improving the physical and mental abilities of the injured worker in order to maximize self-sufficiency and

independence. This would include psychiatric and psychological testing.

RESERVES

See Outstanding Reserves.

STATUS CLOSED

Indicates that the final payment has been made. Closed cases may be re-opened if additional payments are to be made.

STATUS OPEN

As of a specified date, statutory benefit payments are being made or anticipated to be made in the future.

VOCATIONAL REHABILITATION (INDEMNITY)

Training, counseling, evaluation or other services provided a claimant for the express purpose of allowing the injured

worker to resume gainful employment. This would include aptitude and similar testing.

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

Page 4 of 4

Les Form Si-17 - Unit Statistical Report (New Applicant) Page 4