"Insurance Company Initial and Annual Claims Report" - Montana

Insurance Company Initial and Annual Claims Report is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

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INSURANCE COMPANY INITIAL AND ANNUAL CLAIMS REPORT
Instructions: Complete this form and return to the Employment Relations Division prior to May l of each year or upon request
by the Department of Labor and Industry. The information submitted should include all active workers’ compensation claims paid
during the previously completed calendar year. Include the following attachments:
l.
A copy of page 14 "Exhibit of Premiums and Losses-Business in the State of Montana during the Year" of the
annual statement of the preceding calendar year.
2.
Insurer experience claims list showing each open workers' compensation claim to include:
--date of injury
--compensation and medical benefits paid to date
--amounts reserved for future liability as of the preceding calendar year
3.
A listing of all active workers’ compensation policies for the previous calendar year for the State of Montana
including: Effective date, policyholder name, and policy number
GENERAL INFORMATION
YEAR FOR WHICH DATA IS PROVIDED: _______________
Legal Name
DLI
State of
of Insurer
Insurer No.
Domicile
Person(s) to contact regarding: (continue on separate sheet, if necessary).
Security Deposit
Name
Contact
Address
City, State Zip
E-Mail Address
Phone #
Montana Workers
Compensation
Name
Policy Contact
Address
City, State Zip
E-Mail Address
Phone #
INSURANCE COMPANY INITIAL AND ANNUAL CLAIMS REPORT
Instructions: Complete this form and return to the Employment Relations Division prior to May l of each year or upon request
by the Department of Labor and Industry. The information submitted should include all active workers’ compensation claims paid
during the previously completed calendar year. Include the following attachments:
l.
A copy of page 14 "Exhibit of Premiums and Losses-Business in the State of Montana during the Year" of the
annual statement of the preceding calendar year.
2.
Insurer experience claims list showing each open workers' compensation claim to include:
--date of injury
--compensation and medical benefits paid to date
--amounts reserved for future liability as of the preceding calendar year
3.
A listing of all active workers’ compensation policies for the previous calendar year for the State of Montana
including: Effective date, policyholder name, and policy number
GENERAL INFORMATION
YEAR FOR WHICH DATA IS PROVIDED: _______________
Legal Name
DLI
State of
of Insurer
Insurer No.
Domicile
Person(s) to contact regarding: (continue on separate sheet, if necessary).
Security Deposit
Name
Contact
Address
City, State Zip
E-Mail Address
Phone #
Montana Workers
Compensation
Name
Policy Contact
Address
City, State Zip
E-Mail Address
Phone #
Workers’ Comp
Name
Premium Surcharge
Address
Contact
City, State Zip
E-Mail Address
Phone #
Montana
In State Claims
Name
Examiner
Contact
Address
City, State Zip
E-Mail Address
Phone #
Offices Submitting
Name
Quarterly
Expenditure Reports
Address
Contact
City, State Zip
E-Mail Address
Phone #
Carrier/Employer Contacts
NAME
ADDRESS
PHONE #
EMAIL ADDRESS
PREPARER:
Name
Title
Address
E-Mail address:
Phone #
Signature:
Date
Please return by email to: WCRegBureauQER@mt.gov
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