Form SI-08 Enclosure A "Loss Report" - Kentucky

What Is Form SI-08 Enclosure A?

This is a legal form that was released by the Kentucky Labor Cabinet - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2005;
  • The latest edition provided by the Kentucky Labor Cabinet;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form SI-08 Enclosure A by clicking the link below or browse more documents and templates provided by the Kentucky Labor Cabinet.

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Download Form SI-08 Enclosure A "Loss Report" - Kentucky

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ENCLOSURE A
Form SI-08 Rev. 10/05
Employer Name:__________________
Loss Experience Report for Calendar Year(s):______________
NCCI
Vocational
Body Part
OWC
Vocational
Indemnity
Medical
Social
Employee
Employee
Indemnity
Medical
Rehab.
Injury
and/or
Agency
Rehab. Paid
Reserve
Reserve
Security
Last
First
Indicator
Paid as of
Paid as of
Reserve as
SIR
Date
Nature of
Claim
as of
as of
as of
Number
Name
Name
12/31/YR
12/31/YR
of
Injury
Number
12/31/YR
12/31/YR
12/31/YR
12/31/YR
Code
* Please Total Each Individual Year
ENCLOSURE A
Form SI-08 Rev. 10/05
Employer Name:__________________
Loss Experience Report for Calendar Year(s):______________
NCCI
Vocational
Body Part
OWC
Vocational
Indemnity
Medical
Social
Employee
Employee
Indemnity
Medical
Rehab.
Injury
and/or
Agency
Rehab. Paid
Reserve
Reserve
Security
Last
First
Indicator
Paid as of
Paid as of
Reserve as
SIR
Date
Nature of
Claim
as of
as of
as of
Number
Name
Name
12/31/YR
12/31/YR
of
Injury
Number
12/31/YR
12/31/YR
12/31/YR
12/31/YR
Code
* Please Total Each Individual Year