Self Insurance Questionnaire {WCSI-16}

STATE OF NEW HAMPSHIRE Department of Labor Concord, NH 03301 WORKERS' COMPENSATION SELF-INSURANCE QUESTIONNAIRE Name of Self-Insurer _________________________________________________________________ Address ____________________________________________________________________________ ___________________________________________________________________________________ Contact Name: _____________________________________________Fed. ID #___________________ Email: ________________________________ Telephone: __________________________________ The following information is supplied for Labor Department use only for PAID workers' compensation benefits under NEW HAMPSHIRE LAW for calendar year ___________ or your fiscal year that ended in calendar year _____________. Period covered: From_____________20________through____________20______________ $_______________ _______________ 1. 281-A: 23 Medical, Hospital and Remedial Care 2. 281-A: 25 Vocational Rehabilitation 3. 281-A: 26 Compensation for Death (a) Dependent Benefits (b) Burial Expenses $ _______________ $ _______________ Total (a) & (b) 4. 281-A: 28 Compensation for Total Disability (Statutory payments only, please exclude supplemental sick leave benefits) 5. 281-A: 29 Adjusted Total Disability (If any) 6. 281-A: 31 Compensation for Temporary Partial Disability 7. 281-A: 32 Scheduled Permanent Impairment Awards 8. 281-A: 37 Lump Sum Payments TOTAL (1 through 8) $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ (Signed)_________________________________________________ _________________________________________________ Title _________________________________________________ Date WCSI-16 (12/7/10) Questionnaire American LegalNet, Inc. www.FormsWorkFlow.com