Form 102 "Trustee Confirmation of Receipt Workers' Compensation Self-insured Group Quarterly Financial Statements" - Kentucky

What Is Form 102?

This is a legal form that was released by the Kentucky Department of Insurance - 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 July 1, 2020;
  • The latest edition provided by the Kentucky Department of Insurance;
  • 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 102 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

ADVERTISEMENT
ADVERTISEMENT

Download Form 102 "Trustee Confirmation of Receipt Workers' Compensation Self-insured Group Quarterly Financial Statements" - Kentucky

Download PDF

Fill PDF online

Rate (4.7 / 5) 27 votes
Page background image
Commonwealth of Kentucky  Department of Insurance  500 MeroStreet  P.O. Box 517 Frankfort, KY
502-564-6082  FAX 502-564-4604
40602
Trustee Confirmation of Receipt Workers’
Compensation Self-Insured Group
Quarterly Financial Statements
I, ____________________________ affirm that I held the position of Trustee for
_______________________________________ as of the quarter ended ___________,
and hereby acknowledge receipt of a copy of the financial statements for that reporting
period.
___________________________________
Signature
___________________________________
Date
This form is to be completed by all trustees holding the position at the end of each of the three
quarterly reporting periods within a fund year. The deadline for the receipt is 75 calendar days
after the close of each quarterly reporting period.
Mail completed forms to:
U.S. Mail: Kentucky Department of Insurance
P.O. Box 517
Frankfort, KY 40602-0517
Attn: Financial Standards and Examination Division
Express:
Kentucky Department of Insurance
500 Mero Street
Frankfort, KY 40601
Attn: Financial Standards and Examination Division
Form 102 (rev 07/2020 )
Commonwealth of Kentucky  Department of Insurance  500 MeroStreet  P.O. Box 517 Frankfort, KY
502-564-6082  FAX 502-564-4604
40602
Trustee Confirmation of Receipt Workers’
Compensation Self-Insured Group
Quarterly Financial Statements
I, ____________________________ affirm that I held the position of Trustee for
_______________________________________ as of the quarter ended ___________,
and hereby acknowledge receipt of a copy of the financial statements for that reporting
period.
___________________________________
Signature
___________________________________
Date
This form is to be completed by all trustees holding the position at the end of each of the three
quarterly reporting periods within a fund year. The deadline for the receipt is 75 calendar days
after the close of each quarterly reporting period.
Mail completed forms to:
U.S. Mail: Kentucky Department of Insurance
P.O. Box 517
Frankfort, KY 40602-0517
Attn: Financial Standards and Examination Division
Express:
Kentucky Department of Insurance
500 Mero Street
Frankfort, KY 40601
Attn: Financial Standards and Examination Division
Form 102 (rev 07/2020 )