"Workers' Compensation Self-insurance Financial/Loss Update" - Montana

Workers' Compensation Self-insurance Financial/Loss Update is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • Released on December 31, 2020;
  • The latest edition currently provided by the Montana Department of Labor and Industry;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

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Montana Department of Labor & Industry
Employment Relations Division
Street: 1805 Prospect Ave.
City/State/ZIP: Helena, Montana 59601
amclean@mt.gov
Phone: (406) 444-1555 Fax: (406) 444-4140
Email:
Website:http://erd.dli.mt.gov/work-comp-
regulations/insurance-compliance/self-
Date Stamp - Office Use Only
insurance/cancelled-carrier
Workers' Compensation Self-Insurance
Financial / Loss Update
Self-Insured Period:
From:
To:
(mm/dd/yyyy)
(mm/dd/yyyy)
GENERAL INFORMATION
Name of Company:
Federal Employer Tax ID #:
Address:
Parent Company :
Address:
Company Official(s) to Contact Regarding Self-Insurance:
Name
Title
Address
E-Mail
Phone No.
1
GENERAL INSTRUCTIONS
1 Include only the claims information for the time you were self-insured.
2 In the “Accident and Claims Summary” section, please report claim figures for open claims only.
3 Provide the "Undiscounted Total Estimated Unpaid Liability on All Montana Self-Insured Claims" in that section.
This figure should be reported for claims incurred before 7/1/1989 and claims incurred after 7/1/1989.
4 Provide the "Total Cash Paid for Self-Insured Claims During Most Current Year" in that section.
Please enter year (mm/dd/yyyy). The total amount should equal all the checks written for
workers' compensation in Montana in the last calendar year.
5 Provide two (2) copies of your most recent annual report or audited financial statements.
6 Sign and return the financial loss update form to the address listed above.
File: Cancel App revised 12/31/2020
Montana Department of Labor & Industry
Employment Relations Division
Street: 1805 Prospect Ave.
City/State/ZIP: Helena, Montana 59601
amclean@mt.gov
Phone: (406) 444-1555 Fax: (406) 444-4140
Email:
Website:http://erd.dli.mt.gov/work-comp-
regulations/insurance-compliance/self-
Date Stamp - Office Use Only
insurance/cancelled-carrier
Workers' Compensation Self-Insurance
Financial / Loss Update
Self-Insured Period:
From:
To:
(mm/dd/yyyy)
(mm/dd/yyyy)
GENERAL INFORMATION
Name of Company:
Federal Employer Tax ID #:
Address:
Parent Company :
Address:
Company Official(s) to Contact Regarding Self-Insurance:
Name
Title
Address
E-Mail
Phone No.
1
GENERAL INSTRUCTIONS
1 Include only the claims information for the time you were self-insured.
2 In the “Accident and Claims Summary” section, please report claim figures for open claims only.
3 Provide the "Undiscounted Total Estimated Unpaid Liability on All Montana Self-Insured Claims" in that section.
This figure should be reported for claims incurred before 7/1/1989 and claims incurred after 7/1/1989.
4 Provide the "Total Cash Paid for Self-Insured Claims During Most Current Year" in that section.
Please enter year (mm/dd/yyyy). The total amount should equal all the checks written for
workers' compensation in Montana in the last calendar year.
5 Provide two (2) copies of your most recent annual report or audited financial statements.
6 Sign and return the financial loss update form to the address listed above.
File: Cancel App revised 12/31/2020
Page 2
Montana Workers’ Compensation
Self-Insurance Financial / Loss Update
ACCIDENT and CLAIM SUMMARY for SELF-INSURED PERIOD ONLY
(check one)
Claims reported on:
Policy Year
Fiscal Year
Calendar Year
From:
To:
(enter period of self-insurance)
ALL OPEN CLAIMS:
All years
- GRAND TOTALS
(Open Claims Only)
Summary
- attach additional pages
- showing each claim year breakdown
Total payments made:
$
(line 1)
Unpaid reserves, without IBNR,
as of end of most recent year:
$
(line 2)
Total incurred liability
without IBNR updated
as of end of most recent year:
0.00
$
(line 1+ line 2)
Expected recoveries from
excess insurance carrier
$
Number of open claims
When were Reserves last updated?
Undiscounted Total Estimated UNPAID Liability On All Montana Claims:
For claims incurred before 7/1/89:
$
For claims incurred after 7/1/89:
$
Total Claims:
0.00
$
(sum of line 2 above)
From:
To:
(enter year)
Total Cash Paid during
Indemnity + Medical
+ Other
= Total
Last Calendar Year
0.00
$
$
$
$
Medical payments in excess of $200,000 per claim
$
This information is reported by the firm by an authorized person.
I certify that all of the information provided is correct.
Typed Name
Title
Phone
Date
Authorized Signature
E-Mail
File: Cancel App revised 12/31/2020
Page ______
Montana Workers’ Compensation
Self-Insurance Financial / Loss Update
(Reproduce this page as needed)
ACCIDENT and CLAIM SUMMARY for SELF-INSURED PERIOD ONLY
Open Claims Only by Claim Year
Year
Year
Year
Year
Total payments made: (line 1)
Unpaid reserves, without IBNR,
as of end of most recent year: (line 2)
Total incurred liability, without IBNR,
updated as of most recent year-end:
(line 1+ line 2)
0.00
0.00
$ 0.00
0.00
Expected recoveries from
excess insurance carrier
Number of open claims
Open Claims Only by Claim Year
Year
Year
Year
Year
Total payments made: (line 1)
Unpaid reserves, without IBNR,
as of end of most recent year: (line 2)
Total incurred liability, without IBNR,
updated as of most recent year-end:
(line 1+ line 2)
0.00
0.00
0.00
0.00
Expected recoveries from
excess insurance carrier
Number of open claims
Open Claims Only by Claim Year
Year
Year
Year
Year
Total payments made: (line 1)
Unpaid reserves, without IBNR,
as of end of most recent year: (line 2)
0.00
Total incurred liability, without IBNR,
updated as of most recent year-end:
(line 1+ line 2)
0.00
0.00
0.00
0.00
Expected recoveries from
excess insurance carrier
Number of open claims
If no open claims in claim year, then leave blank
Note: Carry the sum of all years and report the grand totals on Page 2.
File: Cancel App revised 12/31/2020
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