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Instructions: Private Self Insurer'S Annual Report - 2000 - Department Of Industrial Relations Page 3

Type of report. This should be an original report, unless used for an interim report or sent

subsequently to the original report to correct an error.

A. Cases and benefits.

Report the cases open as of 12/31/2000 that were reported prior to 1996 for the self

insured company.

2a-e. Report the 1996, 1997, 1998, 1999 and 2000 claim liabilities in the split format. For

each of these years report the liability figures for both All cases reported and Cases

open.

The Future Liability $ Indemnity and $ Medical entry boxes for years 1996-2000

are centered, because the future liability for any given year should be the same as

All cases reported and Cases open in that year. Also remember that the cases and

benefits table should add mathematically both horizontally by year and vertically

for the future liability.

The Incurred Liability entries minus the Paid to Date entries equal the Future

Liability entries.

Each $ Indemnity entry for each year adds mathematically across the table, and

each $ Medical entry for each year likewise adds up across the table.

Future Liability $ Indemnity entries for years 1996, 1997, 1998, 1999 and 2000

(2a-e) are the same amount in any given year’s line, whether you are calculating All

cases reported or Cases open for that particular year. Similarly, the Future Liability

$ Medical entry for each of those years should be the same number for any given

year, whether you are calculating All cases reported or Cases open for that

particular year.

Self Insurance Plans (SIP) does check the math—it must add horizontally across the

page, and it must also add vertically down the Future Liability columns.

We will reject reports that do not calculate correctly.

B. Employment and wages paid in calendar year 2000.

Report the total wages and salaries paid, and the total number of employees—not the

average number and not full employee equivalents. To help calculate the number of

employees, page 2 asks for the number of W-2 tax forms issued to any employee in

California for the given year.

Note: Revoked self insurers should provide employment wage information for three years

after revocation. This data is used to determine the private sector license fee assessment

(Title 8, Chapter 8, Subchapter 2, Article 4, Assessments). The data is also used to

Instructions: Private Self Insurer'S Annual Report - 2000 - Department Of Industrial Relations Page 3