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Self Insurer Report Of Losses Non Experience Rating Period 2810 - Oregon

Self Insurer Report Of Losses Non Experience Rating Period Form. This is a Oregon form and can be used in Self Insured Employer Workers Comp .
 Fillable pdf Last Modified 10/29/2008
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Self-Insurer Report of Losses Non-Experience Rating Period Workers' Compensation Division Page 1 of to Valuation date: January 1, Period covered: Self-insurer name: In accordance with OAR 436-050, all self-insured employers are required to submit claims loss data to the department for calculation of security deposit. The following information must be submitted by March 1: All claims with dates of injury prior to the experience rating period that have outstanding reserves as of January 1 must be reported. Attach the required PTD/Fatal Claim Reserve Worksheets. See instructions relating to the submission of these worksheets. Date of injury Total paid (a) Outstanding reserves (b) Total incurred losses (a+b) $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 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) Worker's name Claim no. CAT, SIR, WDP, PTD, F, rd nd 3 , 2 injury $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Ref: Bulletin 209 440-2810 (8/07/DCBS/WCD/WEB) 2810 American LegalNet, Inc. www.FormsWorkflow.com Self-Insurer Report of Losses, Non-Experience Rating Period Worker's name Date of injury Claim no. Total paid (a) Outstanding reserves (b) Page 2 of Total incurred losses (a+b) $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CAT, SIR, WDP, PTD, F, rd nd 3 , 2 injury Totals (transfer to Page 1): 440-2810 (8/07/DCBS/WCD/WEB) $0.00 $0.00 $0.00 American LegalNet, Inc. www.FormsWorkflow.com
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