Maryland > Workers Compensation > Adjudication Claims
Information Report A-01 - Maryland
| Information Report Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation . |
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Phone: 410-864-5292 E-mail: tmurphy@wcc.state.md.us Fax: 410-864-5291 Maryland Workers' Compensation Commission Insurance Division ANNUAL A-01 REPORTING This is the Information Report (A-01) for period ended June 30, 2006. Complete the form in Acrobat (version 5.x or 6.x recommend to save a copy to your PC), print, sign, certify, notarize, and mail the original along with the requested exhibits (Section IX.). Complete and return the A-01 to this office no later than August 31st , 2006. All self- insurers are also required to submit an independently prepared actuarial report (valued as of the cut-off date of the A-01) no later than September 30, 2006. There have been two personnel changes this year that impact the self- insurance program. Steve n Jones will be transferring to the Fiscal Services Division (effective 7/19/06). We hope to backfill this loss very quickly. Evelyn Fuller has joined the staff as a compliance officer and will be working on selfinsurance and employer compliance programs. We have modified the A-01 form to eliminate the paid losses schedule. We have requested that you provide a copy of the annual claims payment summary report sent to Joyce Campbell, the Commission's Statistics Section, as an attachment to the report. We have revised or added definitions to bring clarity to Sections V VII. In this regard, anticipated future audits will focus on the correctness and appropriateness of this information. Significant variances could result in penalties or other action as provided for in COMAR 14.09.10.08C and D. As always, please feel free to contact the Insurance Division with questions or concerns by email or phone as indicated. Phone: 410-864-5292 Fax: 410-864-5291 E-mail: tmurphy@wcc.state.md.us MDWCC A - 01. (Rev.6/06) Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com Phone: 410-864-5292 E-mail: tmurphy@wcc.state.md.us Fax: 410-864-5291 Maryland Workers' Compensation Commission INSURANCE DIVISION GENERAL INSTRUCTIONS FOR A-01 1. All questions must be answered. State "None" or "Not Applicable" if such is the case. 2. If additional space is required to respond to any of the questions, please include a separate sheet of paper. Be sure to mark it "Form A-01 2006" with the name of the self- insured employer and the date. 3. Mail completed form to: Tom Murphy, CPA Director, Insurance Division MD Workers' Compensation Commission 10 East Baltimore Street, Room 615 Baltimore, MD 21202 4. Be sure that you have the A-01 certified and notarized before returning it. 5. Please provide loss runs on a disk or CD in text or Excel format. DEFINITIONS FOR A-01 Section V Claims Data a. Accidents during current reporting year (Form SF-1) First Report of Injury Submitted to Commission. b. Accidents resulting in injured workers submitting claims to the Commission during the year Total issued Commission claim numbers based on date filed with the Commission (not date of injury). c. Accidents during the year (reporting period) with incurred losses All claims listed on loss run for the current year including those not submitted to the Commission based on date of accident. Section VI Reserves a. Ultimate loss net of payments including incurred but not reported If not supported by an independently prepared actuarial report, an internally prepared estimate is acceptable. This year's report requires an independently prepared actuarial study. b. Open claims/case reserves This amount should agree with the sum of all unpaid losses plus reserves for future anticipated losses as shown on the loss run. MDWCC A-01. (Rev.6/06) Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com Phone: 410-864-5292 E-mail: tmurphy@wcc.state.md.us Fax: 410-864-5291 Section VII Incurred Losses The incurred losses reported on this schedule should be supported by the loss run data submitted with this report (this statement also applies to loss runs submitted with prior year reports). For each of the three years, the "Total Incurred as Adjusted" column should agree with the sum of all incurred losses on the current year loss run based on date of accident. The incurred losses "originally reported," for the current year should be the same as the "as adjusted" column. The first and second prior year amounts should be as reported in the prior year A-01 report in the "as adjusted" column for the current and first prior year. The "Adjustment to Prior Year" should be the calculated difference between the original and as adjusted columns. The assumption is that the amount of the adjustment represents changes in payments and reserves since the last report and loss run submission. Section VIII. Excess Coverage and Security Deposit Information a. Report the self- insured retention on the Excess Workers' Compensation policy b. Report the policy limit (i.e., Statutory, 100,000,000, etc.) The A-01 is to be submitted no later than August 31, 2006. If an extension of time to file this report is needed, a written request must be received by the Commission (Insurance Division) no later than August 15, 2006. Failure to respond by the designated date may result in a penalty pursuant to COMAR 14.09.10.08C. If you have any questions, please contact the Insurance Division: Tom Murphy, CPA (410)864-5292 (410)864-5291 (FAX) tmurphy@wcc.state.md.us NOTE: The Report of Payroll (Form A-02) and Assessment Notice are sent separately by the Commission's Fiscal Services Division and should be returned to them as indicated. If you have any questions regarding the Form A-02 and Assessment Notice, contact James Moore in the Commission's Fiscal Services Division at (410) 864-5257. MDWCC A-01. (Rev.6/06) Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com Phone: 410-864-5292 E-mail: tmurphy@wcc.state.md.us Fax: 410-864-5291 TERMS AND CONDITIONS OF SELF-INSURANCE Please carefully read the following which are policies and procedures established by the Maryland Workers' Compensation Commission (hereinafter referred to as "Commission") acting under the mandate of Title 9 Workers' Compensation (Subtitle 4. Insurance Coverage) of the Labor and Employment Article and COMAR 14.09.10. Failure to comply with the statues and regulations constitutes grounds for revocation of self-insurance privileges. · SECURITY DEPOSIT The amount and form of the self-insurance security deposit is set by the Commission and cannot be changed without the prior approval of the Commission. · SURETY BONDS The self-insured employer must use the sur
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