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

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

FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY

DIVISION OF WORKERS' COMPENSATION

BUREAU OF OPERATIONS SUPPORT

SELF-INSURANCE SECTION

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

I. 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:

EMPLOYER NAME:

DATE:

Mail completed form to:

Division of Workers' Compensation

Self-Insurance Section

P.O. Box 5497

Tallahassee, FL 32314-5497

LES Form SI-20 (Rev. 09/96)

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