Form A4-40 - Private Self Insurer'S Annual Report - 2000 Page 7
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12NOTE: Self Insured Employer
Page 4
Year Ending December 31, 2000
NOTE:
Complete this page on ALL reports.
IV. RECORDS STORAGE
1. Are claim records stored at any location other than with the current administrator?
Yes
No
If yes, Where?
A. Agency Name
C. Agency Name
A.
Address
A.
Address
A.
City
State
Zip+4
A.
City
State
Zip+4
A.
Phone (
)
A.
Phone (
)
B. Agency Name
D. Agency Name
A.
Address
A.
Address
A.
City
State
Zip+4
A.
City
State
Zip+4
A.
Phone (
)
A.
Phone (
)
V. INSURANCE COVERAGE
1. Are any of your workers’ compensation liabilities in California during the reporting period
1.
covered by a standard workers’ compensation insurance policy?
Yes
No
If Yes:
1. Name of Insurance Company:
1.
Policy Number:
Policy Issue Date:
2. Name of Insurance Company:
2.
Policy Number:
Policy Issue Date:
2. Are any of your workers’ compensation liabilities in California during the reporting period
1.
covered by a specific excess workers’ compensation insurance policy?
Yes
No
If Yes:
1. Name of Carrier:
1.
Policy Number:
Policy Issue Date:
1.
Retention Limit:
2. Name of Carrier:
2.
Policy Number:
Policy Issue Date:
2.
Retention Limit:
3. Do you carry an aggregate (stop loss) workers’ compensation insurance policy?
Yes
No
If Yes:
1. Name of Carrier:
1.
Policy Number:
Policy Issue Date:
1.
Retention Limit:
2. Name of Carrier:
2.
Policy Number:
Policy Issue Date:
2.
Retention Limit:
VI. OPEN INDEMNITY CLAIMS AND CLAIM LOG
A. List of ALL Open Indemnity Claims (by reporting location and by year) reported and with claims (in alphabetical
A.
order) is attached immediately following page 7 of this report.
A.
(You may use the form attached or a computer-prepared printout organized in the same format.)
B. Specific Excess Insurance Policy Pages
ATTACHMENTS:
1. List of Open Indemnity Claims (See instructions under Section VI.)
2. Specific Excess Insurance Policy Pages
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