Form A4-40 - Private Self Insurer'S Annual Report - 2000 Page 4
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12Page 2 (Reverse Side)
IIA. ADMINISTRATOR
A. NAME OF CURRENT ADMINISTRATOR(S)/ADMINISTRATING AGENCY(S) AT THE TIME OF PREPARING THIS REPORT.
A.
1. Name (Person)
Administrative Agency’s
1.
Agency Name
Certificate No.:
A.
A.
1.
Address
or
Self Administered
1.
City
State
Zip+4
A.
A.
2. Name (Person)
Administrative Agency’s
1.
Agency Name
Certificate No.:
A.
A.
1.
Address
or
Self Administered
1.
City
State
Zip+4
A.
A.
3. Name (Person)
Administrative Agency’s
A.
1.
Agency Name
Certificate No.:
1.
Address
or
Self Administered
A.
A.
1.
City
State
Zip+4
A.
4. Name (Person)
Administrative Agency’s
1.
Agency Name
Certificate No.:
A.
A.
1.
Address
or
Self Administered
1.
City
State
Zip+4
A.
B. HAS THERE BEEN A CHANGE IN ADMINISTRATOR/ADMINISTRATIVE AGENCY DURING THE PERIOD OF
B.
THIS REPORT PERIOD?
YES
NO
IF YES, DATE OF CHANGE:
Month
Day
Year
TYPE OF CHANGE:
Change in Administrative Agency
Change to or from Self Administration
C. NAME OF PRIOR ADMINISTRATOR(S)/ADMINISITRATIVE AGENCY(S):
4.
A.
Name
1.
Agency Name
A.
A.
1.
Address
1.
City
State
Zip+4
A.
CERTIFICATION
I declare under penalty of perjury that I have prepared or caused this report to be prepared and I have examined this
consolidated report of this self insurer’s workers’ compensation liabilities. To the best of my knowledge and belief this report
is true, correct and complete with respect to the workers’ compensation liabilities incurred and paid. I further declare under
the penalty of perjury that the estimates of future liability of workers’ compensation claims made in this report reflect the
administrator’s best judgment as to the future liability of claims, using prevailing industry standards, and the signatory
intends Self Insurance Plans to rely upon the representation.
Original Signature of Administrator (Person)
Date
Typed Name of Administrator
Name of Administrative Agency or Employer
Title
Street Address
City
State
Zip+4
Phone No. of Administrator (
)
FAX No. (
)
area code
area code
E-mail Address of Administrator
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