Looking for a South Dakota Department Of Labor Forms And Templates? Download it for free!

Application To Self-Insure Workers' Compensation Liabilities - South Dakota Department Of Labor And Regulation Page 8

7. LOSS DATA

Provide a history of all self-insured South Dakota losses and claim counts by accident year that have occurred up to 12/31/11, going back 12 valuation (accident) years. If applicant has not been

self-insured for 12 years, provide the experience covered by private insurance if available. An accident year consists of all claims occurring during a 12-month period regardless of when the claim

is reported.

Please provide the following through each valuation date:

• Total number of closed counts on a cumulative basis

• Number of open claims on an incremental basis

• Total value of paid losses on a cumulative basis

• Total estimated case reserves on an incremental basis

For example, if accidents occured in 1998 and $500 had been paid on the claims by December 31 1998, enter $500 in the 1998 row under the 12/31/98 valuation date column. If during 1999,

an additional $250 was paid for accidents occuring in 1998, and $1,000 for accidents occurring during 1999, then the following entries would be made under the 12/31/99 valuation date column:

$750 in the row for the accident year 1998 ($500 from the preceding column plus $250 paid during 1999) and $1,000 in the row for accident year 1998. The result would be

Accident

Year

12/31/1997

12/31/1998

12/31/1999

1997

1998

XXXXXX

500

750

1999

XXXXXX

1,000

Note: This cumulating process does not apply to the number of open claims or the outstanding case reserves. Other year valuation dates and other 12-month accident periods can be used if

desired instead of those indicated as long as the changes are applied uniformly and indicated clearly.

Please be aware that if you choose to provide reported data too, it should be on a cumulative basis. Also make sure that for each specific entry, the sum of the case reserves and paid losses

should equal the respective entry in the reported data. The same applies for paid, open and reported counts.

(7.1) MEDICAL ONLY PAID CLAIM COUNT (CLOSED)

Valuation Date

Accident

Year

12/31/2004

12/31/2005

12/31/2006

12/31/2007

12/31/2008

12/31/2009

12/31/2010