Form Si-20 - Report Of Outstanding Workers' Compensation Liabilities

Form Si-20 - Report Of Outstanding Workers' Compensation Liabilities - 1996

STATE OF FLORIDA

BUREAU OF MONITORING AND AUDIT

REPORT OF OUTSTANDING WORKERS’ COMPENSATION LIABILITIES

__________________________________________________________________________________

INSTRUCTIONS: This form must be returned with your Summary Loss Reports. Report the outstanding

reserves on all open claims which you have incurred during the period that you have been self- insured in

the state of Florida . Provide this information through the end of the most recently completed policy year

(same period as used on loss report number 1). Please show cumulative amounts for all subsidiary

companies, and only those liabilities incurred in the state of Florida. List the outstanding liabilities by policy

year on the back of this report.

NAME OF SELF INSURER:

FEIN NUMBER

EVALUATION DATE

__________________________________________________________________________________

TOTAL AMOUNT OF WORKERS’ COMPENSATION LIABILITY:

A. REPORTED LOSSES

_____________________

B. PAID LOSSES

_____________________

C. OUTSTANDING LIABILITY (A - B)

__________________________________________________________________________________

II.

RESERVES FOR LOSSES INCURRED BUT NOT REPORTED

(Note: Estimate this amount for all claims. You should include any

occupational disease exposure that you might have.)

__________________________________________________________________________________

III. MONIES RECOVERABLE FROM THIRD PARTIES:

A. EXCESS INSURANCE

_____________________

B. SPECIAL DISABILITY TRUST FUND

_____________________

C. OTHER _________________________________

_____________________

D. TOTAL AMOUNT RECOVERABLE (A + B + C)

__________________________________________________________________________________

IV. NET OUTSTANDING LIABILITY {I(C) + II - III(D)}

__________________________________________________________________________________

REMARKS:

__________________________________________________________________________________

REPORT COMPLETED BY:

DATE:

EMPLOYER NAME:

__________________________________________________________________________________

Mail completed form to: Division of Workers’ Compensation, Self-Insurance Section,

200 East Gaines Street, Tallahassee, FL 32399-4224

Form SI-20 (Rev 9/96)

Form Si-20 - Report Of Outstanding Workers' Compensation Liabilities - 1996

Related Articles

Related forms

Related Categories