Surplus Distribution Request {WC-265} | Pdf Fpdf Doc Docx | Missouri

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Surplus Distribution  Request {WC-265} | Pdf Fpdf Doc Docx | Missouri

Surplus Distribution Request {WC-265}

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

Alternate TextLast updated: 8/9/2012

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS SURPLUS DISTRIBUTION REQUEST 3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 573-526-3692 www.labor.mo.gov/DWC In order to receive authorization for a surplus distribution, the following form must be completed and returned to: Insurance Unit, Division of Workers' Compensation (DWC), P.O. Box 58, Jefferson City, MO 65102-0058. All surplus distributions must have prior approval from the DWC before disbursement. If you have questions, please call 573-526-3692 for assistance. Group Trust Name __________________________________________________________________________ Term (Trust Year) ___________________________________________________________________________ Amount of Surplus Distribution Requested __________________________________________________ 1. Premium Paid by Trust Members* 2. Investment Income* 3. Sum of 1 and 2* 4. Losses and Loss Adjustment Expenses Paid 5. Administrative Expenses 6. Reserves** 7. IBNR** 8. Prior Surplus Distribution 9. Sum of 4, 5, 6, 7, and 8 _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ 10. Surplus Monies 11. Surplus Monies Remaining after Surplus Distribution Requested 12. Number of Open Cases _____________________ _____________________ _____________________ * Premium paid by trust members and investment income must be supported by an attached income statement. ** Reserves and IBNR must be accompanied by an actuarial opinion. _________________________ (Completed By) _________________________ (Date) WC-265 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com

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