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Selected Data From Audited Financial Statements - Maryland

Selected Data From Audited Financial Statements Form. This is a Maryland form and can be used in Financial Reporting Workers Compensation .
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Maryland Workers Compensation Commission Financial Reporting System Selected Data From Audited Financial Statements Part I - General 1. Name of Company: (From Audit Report) 2. Entity Type: 3. Industry Group: Part II Balance Sheet Note: All numbers are to the nearest dollar. Use minus (-) for negative. No $ signs. Previous Year/Month/Day Current Year/Month/Day Reporting Year Ended: 1. Cash & Equivalents and Short-Term Securities 2. Net Receivables 3. Total Current Assets 4. Total Fixed Assets 5. Total Assets 6. Current Liabilities 7. Long-Term Debt 8. All Other Liabilities (Total Liabilities minus 6 & 7) 9. Equity (Ne tWorth or Ne tAssets) 9 a. Retained Earnings 9 b. Ne tUnrestricted Assets (NFP only) 10. Market Capitalization (BS Date) (Listed Only) Part III Income Statement 11. Total Sales or Revenue 12. Income( Loss) From Operations& Before Interest and DD&A 13. Interest Expense (Show as positive number) 14. Depreciation (DD&A) 15. Income Taxes (Expense [Benefit]) 16. All Other Non-Operatin gItems 17. Net Income (Loss) 1 - 4 <<<<<<<<<********>>>>>>>>>>>>> 2 Maryland Workers Compensation Commission Financial Reporting System Selected Data From Audited Financial Statements Part IV Cash Flow 18. Cash Flow from Operations 19. Purchase of PPE (Show as positive number) 20. Cash From Investing 21. Debt Proceeds Less Pay Downs 22. Cash From Financing 23. Net Cash Flow Part V Hospital and Health Care Organizations Only 24. Gross Patient Revenue 25. Bad Debt Expense 26. Allowance for Bad Debts 27. Fees Waived For Charity Care Comments and Explanations Contact Information Name: Title: Telephone : Email: 2 - 4 <<<<<<<<<********>>>>>>>>>>>>> 3 Maryland Workers Compensation Commission Financial Reporting System Selected Data From Audited Financial Statements INSTRUCTIONS General Consistent with the requirements of LE 9-406(1)(i), the Commission periodically evaluates the financial strength of a self-insured employer (SIE). Information in the audited financial statement submitted annually by the SIE is one tool used to perform this evaluation. The results of such evaluations are taken into consideration along with other data when determining changes in SIE status, such as, changes in retention and security as well as continuing program participation. As an assist in the analysis and evaluation process, the Commission has developed several financial models that score financial performance. The results of such modeling are used as indicators of financial strength and as necessary, drive the extent and direction of further analysis. The financial models are consistent with Altmans Z score evaluation techniques and ratio analysis similar to that published on the Internet for publicly-held companies and in publications such as RMAs Annual l Financial Statistics Disclosure of Information While the financial information provided by the SIE maybe in the public domain, the results of any analysis by the Commission are not. Accordingly, the results of the Commission analysis and evaluation may not be disclosed to any other person outside the Commission consistent with LE1104. T 9- he Commission may from time to time aggregate these statistics to determine trends and industry performance. If such information is made public, it will be in aggregate form only, and will not disclose the name of the organizations whose data is included in the aggregation of any table or array of statistics. Due Date This report is due 30 days after the issuance date of the audited financial statements. A hard copy of the audited financial statements along with the 10-K, if applicable, should be mailed to the following address no later than 30 days after issuance. Maryland Workers Compensation Commission Insurance Division 10 East Baltimore Street Baltimore, Maryland 21202 Conventions All dollar amounts should be entered to the nearest dollar. Use a negative sign only when it is shown as negative is the financial statement except for the purchase of PPE or capital expenditures should always be reported as a positive. Specific Instructions Part I General Item 1 If the SIE is a subsidiary of a publicly-held company, list the name of the publicly-held company providing the parental guarantee. Item 2 Select one of the following Entity Types A. Publicly-Held Corporations B. Privately-Held Corporations C. Not-For-Profit Entities D. Government 3 - 4 <<<<<<<<<********>>>>>>>>>>>>> 4 Maryland Workers Compensation Commission Financial Reporting System Selected Data From Audited Financial Statements Part I General (continued) Item 3 Select one of the following Industry Classifications: 01- Utilities 02 - Airlines 03 - Service 04 - Food 05 - Retail 06 - Manufacturers and Producers 07 - Auto 08 - Energy Oil 09 - Ground Transpiration 10 - Technology 11 - Construction 12 - Dealers 13 - Hospitals and Health Care 14 - Other Non-Profits 15 - School Systems 16 - Other Government Entities 17 - All Other Part II Balance Sheet Year Ended Please enter the dates and financial data for the latest two accounting years. The data must be taken from the audited financial statements. All data elements should be self-explanatory except for item 10. Market capitalization is the number of common shares outstanding times the per share market price of the companys stock as of the balance sheet date. Privately-held and non-profits should leave this data element blank. Part III Income Statement : Self-explanatory Part VI Statement of Cash Flow: Self-explanatory Part V Hospital and Health Care Organizations Only : Self-Explanatory, Item 27 is normally disclosed in the notes to the financial statements Comments and Explanations This space can be used to disclose additional information considered necessarundey forsr tanding the information provided in this report. Contact Information This report should be prepared or reviewed by a member of the organizations financial staff familiar with financial statements. Please provide the name of the individual and contact information for resolving any issues related to this submission. Inquiries about this report should be directed to: Tom Murphy, CPA, Director Insurance Division (410) 864-5292 email: info@wcc.state.md.us. 4 - 4
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