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Instructions: Private Self Insurer'S Annual Report - 2000 - Department Of Industrial Relations Page 8

Name of specific excess carrier—complete, correct name of the carrier, because many

carriers have similar names.

Credit for specific excess coverage can not be extended to insurance companies that are

insolvent, seized, bankrupt, or a non-admitted California surety. However, all claims that fall

into this category must be reported, and the information is helpful in bankruptcy situations.

Since no credit can be given for such cases, enter a zero in the box labeled Total Unpaid

Carrier Liability, after completing all the other information pertaining to the claim.

Policy number—of the specific excess policy covering the claim.

Policy period—start and stop dates of the policy.

Employer’s retention—the amount of loss the self insurer must pay before the carrier will

indemnify it.

Upper policy limit—the insurance policy’s upper limit of indemnity is the maximum amount

of loss for which the carrier will indemnify the self insurer.

Check a yes or no response to: claim reported to carrier, claim acknowledged/accepted by

carrier, has carrier denied any part or all liability of this claim.

Total of payment by excess carrier to date of this claim—the amount the carrier has paid to

date in reimbursements. This amount is for information purposes only, and does not enter

into the calculations for excess credit.

Calculating the unpaid employer retention:

1a. Employer’s retention—stated in the policy, the minimum retention level is the amount

of loss the self insurer must pay on a claim before the carrier will indemnify.

1b. Total paid on claim—use the sum of the paid-to-date indemnity and medical figures on

this claim reported in Section VI, Open Indemnity Claims and Claim Log.

1c. Unpaid employer retention—subtract the total paid on claim from the employer’s

retention to determine any unpaid employer retention. If the employer paid over the

retention level and the total paid on claim is a larger number than the employer’s

retention, enter zero.

Calculating the total unpaid carrier liability:

2d. Estimated future liability on claim—to estimate what remains to be paid on this claim

in indemnity and medical, use the sum of the estimated future liability indemnity and

medical figures reported in Section VI, Open Indemnity Claims and Claim Log.

2e. Unpaid employer retention—the number determined in item 1c above.

Instructions: Private Self Insurer'S Annual Report - 2000 - Department Of Industrial Relations Page 8