Form A4-40 - Private Self Insurer'S Annual Report - 2000 Page 9
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12NOTE: Self Insured Employer
Page 6
Year Ending December 31, 2000
NOTE:
Complete this page on ALL reports.
VIII. DEPOSIT CALCULATION
A. Estimated Future Liability
A.
(From Line 3 of Consolidated Liabilities on Page 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. Minimum Deposit Factor—Known Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
x 135%
B.
Indicate Minimum Deposit Required . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Line BB $
C. Add Deposit for Current Year:
C.
(1) Estimated Future Liability
C. (1)
(From Line A above)
$
C.
(2) Less Future Liability of cases prior to 1996
C. (2)
(From Line 1 of Consolidated Liabilities on Page 2)
- $
+
$ Indemnity
$ Medical
C.
C.
C.
(3) 5 year total unpaid Future Liability
= $
(4) One year average unpaid liability (Divide Line 3 above by “5”) ÷ 5 . . . . . . . . . . Line CC $
C.
C.
(5) Subtotal (Add Line BB and Line CC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subtotal $
D. Total Adjustment for Excess Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - $
D.
Adjusted Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Line DD $
E. Total Deposit All Types (Line AA, Part VII, previous page) . . . . . . . . . . . . . . . . Line AA $
E.
Minimum Deposit Increase Indicated (Line DD—Line AA) . . . . . . . . . . . . . . . . . . . . . . . $
E.
Increase is Due by May 1.
(
)
E.
Minimum Deposit Decrease Indicated (Line DD—Line AA) . . . . . . . . . . . . . . . . . . . . . . . . $
NOTE: Labor Code Section 3701(a) requires every private, self-insuring employer to secure incurred liabilities for the
payment of compensation by renewing or making a new deposit of security within 60 days of filing of this annual
report, but in no event later than May 1 of each year. Civil penalties of up to $5,000 for every 30 days or portion
thereof that there is a failure to post deposit may be assessed by the Director of Industrial Relations pursuant to
Labor Code Section 3702.9 for failure to post required deposit when due.
CERTIFICATE OF COMPANY OFFICER
I declare under the penalty of perjury that I have examined this Self Insurer’s Annual Report and to the best of my knowledge and
belief it is true, correct and complete. I am also aware of our company’s duty to post and maintain the required security deposit that is
due as a result of this report.
Signature of Company Officer
Date
Typed Name of Company Officer
Name of Company
Title
Street Address
City
State
Zip+4
Phone No. (
)
area code
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