Form A4-40 - Private Self Insurer'S Annual Report - 2000 Page 12
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12Page
of
Pages
LIST OF OPEN INDEMNITY CASES
AS OF
______________________________________
(Date)
Reporting Location No.:
All Cases on this Page are
For the Year
Certificate Number:
NAME OF MASTER CERTIFICATE HOLDER:
Name of Insured or Deceased
Date of
Description of Injury
Paid to Date
Estimated Future Liability
(Last)
(First Initial)
Injury
$ Indemnity
$ Medical
$ Indemnity
$ Medical
(List Alphabetically within year)
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