Form Si-17 - Self-Insurance Unit Statistical Report

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SELF-INSURANCE
UNIT STATISTICAL REPORT
REPORT NO.
1 [ ] 2 [ ] 3 [ ]
EMPLOYER NUMBER
ACCOUNT NUMBER
BEGINNING DATE
ENDING DATE
_________________________________________________________________________________________
EMPLOYER NAME (s)
CLAIM NUMBER OR
STATUS
INJURY
PAYROLL
DATE OF
INCURRED
LOSS
_
NUMBER OF CLAIMS
CODE
CLASS
ACCIDENT
CODE
(EXCESS
MEDICAL
INDEMNITY
CLAIMS
ONLY)
TOTALS
ENTER BELOW TOTAL ALLOCATED LOSS
REPORT COMPLETED BY:
ADJUSTMENT EXPENSE INCURRED
PLEASE RETURN COMPLETED REPORT TO:
Division of Workers’ Compensation
Bureau of Monitoring & Audit
SELF-INSURANCE SECTION
200 E. Gaines St.
TALLAHASSEE, FL 32399-4224
FORM SI-17 (1/2008)
j:\siforms\wwm\si-17

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