Form A4-40 - Private Self Insurer'S Annual Report - 2000 Page 10
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SPECIFIC EXCESS INSURANCE POLICY COVERAGE
Certificate No:
Name of Self Insurer:
Note: Instructions to Claims Administrator—See Reverse Side of this Page.
Name of Claimant
Claim No.
Date of Injury
First Year Reported
To SIP
Description of Injury
Name of Specific Excess Carrier
Policy Number
Policy Period
Employer’s Retention $:
From:
To:
Upper Policy Limit $:
Claim Reported to Carrier?
Yes
No
Claim Acknowledged/Accepted by Carrier?
Yes
No
Has carrier denied any part or all liability of this claim?
Yes
No
Total of payment by excess carrier to date of this claim:
$
Total Paid on Claim
Unpaid Employer Retention
Employer’s Retention
(Indemnity & Medical figures from Section VI)
Enter “0” if “b.” is greater than “a.”
$
$
1
a.
$
Minus
b.
=
c.
Estimated Future Liability on Claim
Unpaid Employer Retention
(From Section VI)
(Item c. above)
Total Unpaid Carrier Liability
$
2
d.
$
Minus
e.
f.
$
=
Name of Claimant
Claim No.
Date of Injury
First Year Reported
To SIP
Description of Injury
Name of Specific Excess Carrier
Policy Number
Policy Period
Employer’s Retention $:
From:
To:
Upper Policy Limit $:
Claim Reported to Carrier?
Yes
No
Claim Acknowledged/Accepted by Carrier?
Yes
No
Has carrier denied any part or all liability of this claim?
Yes
No
Total of payment by excess carrier to date of this claim:
$
Total Paid on Claim
Unpaid Employer Retention
Employer’s Retention
(Indemnity & Medical figures from Section VI)
Enter “0” if “b.” is greater than “a.”
$
$
1
a.
$
Minus
b.
c.
=
Unpaid Employer Retention
Estimated Future Liability on Claim
(Item c. above)
(From Section VI)
Total Unpaid Carrier Liability
$
2
d.
$
Minus
e.
f.
$
=
Name of Claimant
Claim No.
Date of Injury
First Year Reported
To SIP
Description of Injury
Name of Specific Excess Carrier
Policy Number
Policy Period
Employer’s Retention $:
From:
To:
Upper Policy Limit $:
Claim Reported to Carrier?
Yes
No
Claim Acknowledged/Accepted by Carrier?
Yes
No
Has carrier denied any part or all liability of this claim?
Yes
No
Total of payment by excess carrier to date of this claim:
$
Total Paid on Claim
Unpaid Employer Retention
Employer’s Retention
(Indemnity & Medical figures from Section VI)
Enter “0” if “b.” is greater than “a.”
$
1
a.
$
Minus
b.
c.
$
=
Unpaid Employer Retention
Estimated Future Liability on Claim
(From Section VI)
(Item c. above)
Total Unpaid Carrier Liability
$
2
d.
$
Minus
e.
f.
$
=
SUBTOTAL Total Unpaid Carrier Liability This Page: $
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