Self Insurers Compensation Bond (Appendix I)

INSTRUCTIONS FOR FORM IC-211 SELF-INSURED EMPLOYER REPORT OF TOTAL UNPAID LIABILITY NO OPEN CLAIMS HEADING: COLUMN 1: COLUMN 2: ENTER NAME OF SELF-INSURER EMPLOYER, YEAR AND SELECT SEMI-ANNUAL DATE TOTAL NUMBER OF OPEN CLAIMS Enter the number of all open claims as of the "snapshot" reporting date. TOTAL INCURRED MEDICAL ONLY Enter the total incurred liability on all Medical Only claims. Total incurred Medical Only amounts to be reported include all paid and anticipated unpaid liabilities including medical, and allocated expenses if incurred, as of the snapshot reporting date. TOTAL PAID MEDICAL ONLY Enter the total dollar amount paid on Medical Only claims reported in column 2 as of the snapshot reporting date. TOTAL UPAID MEDICAL ONLY Enter the dollar amount of the unpaid portion of the total incurred liability reported in Column 2 (Column 2 minus Column 3). TOTAL INCURRED INDEMNITY (INCLUDING MEDICAL) Enter the total incurred liability on all Indemnity Claims. Total incurred Indemnity amounts to be reported include all paid and anticipated unpaid liabilities including both medical and indemnity, and vocational or allocated expenses if incurred, as of the snapshot reporting date. TOTAL PAID INDEMNITY INCLUDING MEDICAL Enter the total dollar amount paid on all Indemnity claims reported in column 5 as of the snapshot reporting date. TOTAL UNPAID INDEMNITY INCLUDING MEDICAL Enter the dollar amount of the unpaid portion of the total incurred liability reported in column 5 (Column 5 minus Column 6). TOTAL UNPAID LIABILITY Enter the total amount of unpaid liability for all Medical Only and Indemnity claims. (Column 4 plus Column 7). COLUMN 3: COLUMN 4: COLUMN 5: COLUMN 6: COLUMN 7: COLUMN 8: TOTAL UNPAID LIABILTY FROM COLUMN 8 Enter the amount that was calculated on the interactive report form in column 8, above. American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR FORM IC-211 SELF-INSURED EMPLOYER REPORT OF TOTAL UNPAID LIABILITY (cont.) EXCESS INSURANCE CARRIER REIMBURSEMENT EXPECTED If the self-insured employer has coverage under an excess/reinsurance policy for payment or reimbursement of any portion of the amount reported in Column 7 above, that expected reimbursement must be entered on this line. A copy of the full and complete excess insurance policy must be submitted with the Form IC-211 for consideration of coverage credit toward the security deposit requirement. NET REMAINING UNPAID LIABILITY Enter the difference between the Unpaid Liability and the Excess Carrier Reimbursement Expected. EXCESS CARRIER REIMBURSEMENT DETAIL: The self-insured employer will complete this section of the Form IC-211 only if reimbursement is expected from an excess insurance carrier. Each claimant that receives benefits from the excess carrier must be listed individually in this section. In addition to the amounts reported, the selfinsured employer may receive a credit toward the security deposit requirement for Total Unpaid Liability when a copy of the applicable excess insurance policy is also provided. COLUMN 1: COLUMN 2: COLUMN 3: DATE OF INJURY Enter the date the workers' compensation injury occurred. NAME Enter the full name of the injured worker. TOTAL MEDICAL & INDEMNITY INCURRED Enter the total dollar amount for incurred 's injury. relating to each COLUMN 4: TOTAL MEDICAL & INDEMNITY PAID Enter the total dollar amount that has been paid on behalf of each claim. This amount should include everything paid by both the self-insured employer and the excess insurance carrier. EXCESS CARRIER NAME Enter the name of the carrier that has written the excess insurance policy. SPECIFIC RETENTION LIMIT Enter the specific dollar retention limit from the excess insurance policy that covers this claim. EXCESS REIMBURSEMENT COLUMN 5: COLUMN 6: COLUMN 7: COLUMN 8: EXCESS REIMBURSEMENT SELF-INSURED'S AUTHORIZATION AND VALIDATION The IC-211 form must be signed and certified by a corporate officer. The signature does not require a notary. The preparer should be the contact person able to respond to follow-up questions regarding the information reported. American LegalNet, Inc. www.FormsWorkFlow.com 0 0 0 0 0 If you need assistance, please contact one of the following Financial Specialists: Alan Pace at (208) 334-6083 or Shelly Tudela at (208) 334-6026. American LegalNet, Inc. www.FormsWorkFlow.com