Les Form Si-17 - Unit Statistical Report
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1FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY
DIVISION OF WORKERS' COMPENSATION
BUREAU OF OPERATIONS SUPPORT
SELF-INSURANCE SECTION
UNIT STATISTICAL REPORT
Pages
Page ___________ of ___________
REPORT NO.
1
2
3
EMPLOYER NUMBER
ACCOUNT NUMBER
BEGINNING DATE
ENDING DATE
EMPLOYER NAME(s)
DATE OF
INCURRED LOSS
SOCIAL SECURITY NO.
INJURY
PAYROLL
ACCIDENT
OR NUMBER OF CLAIMS
STATUS
CODE
CLASS
(EXCESS
MEDICAL
INDEMNITY
CODE
CLAIMS
ONLY)
TOTALS
ENTER BELOW TOTAL ALLOCATED LOSS
REPORT COMPLETED BY:
ADJUSTMENT EXPENSE INCURRED
PLEASE RETURN COMPLETED REPORT TO:
SELF-INSURANCE SECTION
P.O. BOX 5497
TALLAHASSEE, FL 32314-5497
LES Form SI-17 (09/96)
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