Statement Of Specific And Aggregate Excess Insurance Coverage {WC-121} | Pdf Fpdf Doc Docx | Missouri

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Statement Of Specific And Aggregate Excess Insurance Coverage {WC-121} | Pdf Fpdf Doc Docx | Missouri

Statement Of Specific And Aggregate Excess Insurance Coverage {WC-121}

This is a Missouri form that can be used for Workers Comp.

Alternate TextLast updated: 4/13/2015

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS STATEMENT OF SPECIFIC AND AGGREGATE EXCESS INSURANCE COVERAGE (To Be Filed By Self-Insured) Name of Approved Self-Insured: Address of Self-Insured: Other Named Insureds on Policy: 3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 www.labor.mo.gov/DWC ______________________________________________________________________________ (Please attach separate sheet if necessary) ________________________________________ ________________________________________ ________________________________________ ________________________________________ Insurance Company Issuing Policy: ______________________________________________________________________________ Named State: Missouri To: Policy No. ________________________________________ 1) Policy period: From: ____________________ ____________________ ___________________ ___________________ 2) Specific retention level: Each accident: Each employee for disease: 3) Specific limit each accident: Policy Part One, Workers' Compensation: ____________________ 4) Specific limit each employee for disease: Policy Part One, Workers' Compensation: ____________________ 5) Aggregate excess retention: Normal premium multiplied by: ___________________ 6) Aggregate excess limit: ___________________ Minimum retention: ___________________ Policy Part Two, Employers Liability: ____________________ Policy Part Two, Employers Liability: ____________________ 7) Check here if aggregate excess coverage is not purchased. __________________ _________________________________________________________________ Signature (Representative of self-insured entity or insurance company only) I swear the above information is true under penalty of perjury. To remain in compliance with The Rules Governing Self-Insurance 8 CSR 50-3.010 (3)(B)3 or 8 CSR 50-3.010 (5)(B)2, the insurance company must: A. Be AM Best rated A- or better, B. Be an admitted carrier by the Missouri Department of Insurance, Financial Institutions and Professional Registration, and C. Provide the division, by certified mail, notice of cancellation or nonrenewal sixty (60) days before actual termination. ____________________________________ Date ____________________________________________________________________________________________________________ Company Name and Address Missouri Division of Workers' Compensation is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. WC-121 (05-13) AI American LegalNet, Inc. www.FormsWorkFlow.com

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