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Instructions: Private Self Insurer'S Annual Report - 2000 - Department Of Industrial Relations Page 6

Attach a list of all open indemnity claims. This list may be on the List of Open Indemnity

Cases provided at the end of the annual report form, or a computer run organized in the same

format. If the list of cases is a computer run, it must include the: name of insured, date of injury,

description of injury, paid to date and estimated future liability. The listing must be by year and

alphabetical within each year.

Instructions: Page 5

VII. Security Deposit

Complete the security deposit information. Include all types of security currently deposited as

security for your self insurance program. For the convenience of self insurers, on your copy of

the annual report mailing we have attached a list of the security deposits we have on record.

Instructions: Page 6

VIII. Deposit Calculation

This section is used to determine the required security deposit. If you have claims on the List of

Open Indemnity Cases that exceed the retention level of the specific excess policy, you need to

first complete both sides of page 7—to calculate the total adjustment for excess

coverage—before completing page 6.

A. Estimated future liability. This figure comes from page 2, Consolidated Liabilities, item 3.

B. Minimum deposit factor. This is 135% unless otherwise applicable to the self insurer. For

example, many self insurers have a 200% deposit rate required.

Multiply item A by item B to determine the minimum deposit required on Line BB.

C. Add deposit for current year. This calculates a deposit for the current year to secure average

unpaid liability in the current year’s new claims. The number is added to the minimum

deposit required number.

D. Total adjustment for excess coverage—see page 7 for instructions on calculating excess.

This amount is deducted from the required deposit amount, because this amount is

documented as covered by an excess insurance policy and gives you the adjusted total.

E. Total deposit all types. This number is derived from page 5, Security Deposit, and is the

total security deposit currently posted with SIP.

Instructions: Private Self Insurer'S Annual Report - 2000 - Department Of Industrial Relations Page 6