Missouri > Workers Comp
Annual Reporting Forms For Self Insured Trusts WC-135 - Missouri
| Annual Reporting Forms For Self Insured Trusts Form. This is a Missouri form and can be used in Workers Comp . |
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2011 Workers' Compensation Trust Self-Insurance Annual Reporting WC-135 (11-11) AI American LegalNet, Inc. www.FormsWorkFlow.com MEMORANDUM TO: FROM: SUBJECT: Self-Insurance Group Trust Administrators Insurance Unit Workers' Compensation Group Trust Self-Insurance Annual Reporting 2011 Annual Report for Self-Insured Trusts In keeping with the Rules Governing Self-Insurance 8 CSR 50-3.010 (6)(A), the self-insured group trusts need to complete the enclosed 2011 Annual Report for Self-Insured Trusts WC-135 Form [8 pages] and provide the following information to the Division of Workers' Compensation (Division): a) General Information; b) Trustee Information; c) Historical Data; d) Investments; e) Claim Development Report; and f) Incurred But Not Reported (IBNR) Surplus Report. All group trusts, active and terminated, must complete the WC-135 Form as long as there are active claims. The information contained in this report is to be based on the 2011 calendar year. All Division forms are on our website at www.labor.mo.gov/DWC. You may fill out the WC-135 Form online, print it off, and mail it to the address below. The direct website to obtain this form is www.labor.mo.gov/DWC/Forms/WC-135-AI.pdf. Please complete the WC-135 Form and submit it to the Division of Workers' Compensation, P.O. Box 58, Jefferson City, MO 65102-0058. This form must be returned to our office by May 31, 2012. Additionally, note that the Rules Governing Self-Insurance 8 CSR 50-3.010 (6)(A)1 require group trusts to file annual financial reports within 150 days after the close of the trust's fiscal year. The documentation or reports that need to be submitted annually and quarterly to the Division are available on our website. The Division continues to conduct audits relating to safety, claims and any other audits deemed necessary and appropriate by the Division as provided in 8 CSR 50-3.010(9)(A). The Division has enjoyed working with you during the past year and we look forward to continued success for the upcoming year. Should you have any questions, or need any assistance regarding the above information, please contact the Insurance Unit at 573-526-6021. Enclosures WC-135-2 (11-11) AI American LegalNet, Inc. www.FormsWorkFlow.com GENERAL INFORMATION 1. GROUP TRUST Name of Group Trust Executive Director (Name) Address Type of Group Trust City, State, ZIP Code Telephone Number 2. SPONSORING ASSOCIATION (If Applicable) Name of Sponsoring Association Address City, State, ZIP Code 3. PLAN ADMINISTRATOR Name of Plan Administrator Contact Name and Title Address Location of Books & Claim Records E-mail City, State, ZIP Code Telephone Number 4. CLAIMS ADMINISTRATOR Name of Claims Administrator Contact Name and Title Address E-mail City, State, ZIP Code Telephone Number 5. ACTUARIAL INFORMATION Name of Actuary Contact Name Address E-mail City, State, ZIP Code Telephone Number 6. CERTIFIED PUBLIC ACCOUNTANT INFORMATION Name of Certified Public Accountant Contact Name Address E-mail City, State, ZIP Code Telephone Number 7. SAFETY (In house contact) Name of Safety Manager/Administrator Telephone Number Address E-mail City, State, ZIP Code Do you use an outside safety consultant? Yes (If "Yes," please complete the following information.) Name of Safety Consultant Telephone Number Address E-mail No City, State, ZIP Code WC-135-3 (11-11) AI American LegalNet, Inc. www.FormsWorkFlow.com TRUSTEE INFORMATION BOARD OF TRUSTEES The Rules Governing Self-Insurance, 8 CSR 50-3.010 (7), require the board of trustees to have at least five (5) persons elected from membership of the trust, association, or organization for stated terms of office, to direct the administration of the trust. Please provide information for trustees. Name of Trustee Member Affiliation Address Title Telephone Number City, State, ZIP Code Name of Trustee Member Affiliation Address Title Telephone Number City, State, ZIP Code Name of Trustee Member Affiliation Address Title Telephone Number City, State, ZIP Code Name of Trustee Member Affiliation Address Title Telephone Number City, State, ZIP Code Name of Trustee Member Affiliation Address Title Telephone Number City, State, ZIP Code OTHER TRUSTEES Trustee Name Trustee Name Trustee Name Trustee Name Trustee Name Title Title Title Title Title WC-135-4 (11-11) AI American LegalNet, Inc. www.FormsWorkFlow.com HISTORICAL DATA 1. FINANCIAL INFORMATION *Earned Annual Premium Claims Paid Claims Reserves Incurred But Not Reported (IBNR) Total Administrative Expenses Including Taxes Level of Surplus As of 12-31 2. MISCELLANEOUS INFORMATION Total Number of Current Members in the Trust Total Number of Current Employees in the Trust Average Monthly Payroll of the Trust **Loss Ratio Administrative Expense Ratio Estimated Premium if Insured on Open Market ***Federal Employers Identification Number (FEIN) As of 12-31 * Earned Annual Premium (EAP) EAP is computed by applying the appropriate payroll code classification rates to the trust member's annual payroll and multiplying the results by the experience modification factors of the trust members as developed by the advisory organization approved by the Department of Insurance and including any other discounts and surcharges. ** Loss Ratio Total sum of claims paid and claims reserves and dividing the results by earned annual premium. *** Federal Employer Identification Number (FEIN) If your trust has not obtained a FEIN, please state "n/a". WC-135-5 (11-11) AI American LegalNet, Inc. www.FormsWorkFlow.com CASH & INVESTMENTS as of 12-31 The Rules Governing Self-Insurance 8 CSR 50-3.010 (7)(B) limit the type of investment activity for self-insured trusts to: U.S. Treasury Bills, Notes or Bonds, Certificates of Deposits issued by a duly chartered commercial bank, or a transaction account of the designated depository. Please complete the following investment schedule: INVESTMENT SCHEDULE Investment Type U.S. Treasury Bills U.S. Treasury Bonds U.S. Notes Certificates of Deposits Total Purchase Price Current Fair Market Value Upon Division approval, regulation 8 CSR 50-3.010 (7)(D) permits 25 percent of surplus money from a prior trust year to be invested in securities designated by the Office of State Treasurer as acceptable collateral to secure state deposits pursuant to section 30.270.1, RSMo. Please complete the following investment schedule if your trust has invested in any securities not listed above. INVESTMENT SCHEDULE Investment Type Purchase Price Current Fair M
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