Oregon > Workers Comp > Self Insured Employer
Self Insurer Report Of Losses Experience Rating Period 2809 - Oregon
| Self Insurer Report Of Losses Experience Rating Period Form. This is a Oregon form and can be used in Self Insured Employer Workers Comp . |
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Self-Insurer Report of Losses Experience Rating Period Workers' Compensation Division Page 1 of Period covered: Self-insurer name: to Valuation date: Jan. 1, This report is used to calculate the annual experience rating modification and to make retrospective rating plan adjustments. The data will also be used to calculate the selfinsurer security deposit. The following information must be submitted by March 1: Report all losses that occurred during the period above. Attach the required PTD/Fatal Claim Reserve Worksheets. See instructions relating to the submission of these worksheets. Refer to "Report of Losses Instructions" for explanation of the following: ............................................................................................ A. Nurse/physician/contract medical for the above period (Once the amount is reported, the same amount must be reported for each of the three experience years.) $ -+$ B. Claims with incurred losses of $5,000 or less $ = (Total paid) (Medical deductible) (Outstanding reserves) $ $ (Total incurred losses) (Number) - C. D. Total number of claims with medical deductible ....................................................................................................................... Total number of all claims, including medical deductible claims, with incurred losses of $5,000 or less ............................... (Number) E. Complete the following for each claim with incurred losses exceeding $5,000: Date of injury (in fiscal yr) Medical deductible (if previously reported) (b) Worker's name Last, first, middle initial Claim no. Total paid (a) $ $ $ $ $ $ $ $ $ Outstanding reserves (c) $ $ $ $ $ $ $ $ $ - Total incurred losses (a-b+c) $ $ $ $ $ $ $ $ $ - CAT, SIR, PTD, F, 3rd party $ $ $ $ $ .......................................................................................... $ Totals, this page: Totals from page 2: .................................................................................. $ ......................................................................... $ Totals from additional pages: $ Totals for above year: # of claims (Include total number of claims from attached pages) 440-2809 (12/05/DCBS/WCD/WEB) Ref: Bulletin 209 2809 American LegalNet, Inc. www.FormsWorkFlow.com Self-Insurer Report of Losses, Experience Rating Period Worker's name Last, first, middle initial Date of injury (in fiscal yr) Medical deductible (if previously reported) (b) Page 2 of CAT, SIR, PTD, F, 3rd party - Claim no. $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total paid (a) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Outstanding reserves (c) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ - Total incurred losses (a-b+c) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Totals (transfer to page 1): ยท440-2809 (12/05/DCBS/WCD/WEB) $ - $ - $ - $ - American LegalNet, Inc. www.FormsWorkFlow.com
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