Claims Reserved In Excess Of Self-Insured Retention
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Claims Reserved In Excess Of Self-Insured Retention Form. This is a Oregon form and can be use in Self Insured Employer Workers Comp.
Loading PDF...
Tags: Claims Reserved In Excess Of Self-Insured Retention, 2937, Oregon Workers Comp, Self Insured Employer
CLAIMS RESERVED IN EXCESS OF SELF-INSURED RETENTION valued as of 1/1/
(year)
Self-Insured:
Worker's name
Last name, first name
Date of
injury
Future
Have claim
liability
covered by Self-insured payments
retention
exceeded
excess
(SIR)
SIR?
insurance
Amount
Amount
Yes or no
Excess insurer name/
policy number
Is selfinsured
receiving
Excess
reimburse- insurer
ment?
notified?
Yes * or no
Yes or no
**Check
here if copy
of written
notification
attached
* If yes, also provide percentage of claim costs being reimbursed.
** Not required if previously submitted to the department, or if receiving reimbursement
FAILURE TO SUBMIT THIS FORM MAY RESULT IN THE AMOUNT OF THE SECURITY DEPOSIT BEING DETERMINED
WITHOUT REGARD TO EXCESS INSURANCE REIMBURSEMENT.
If you have questions regarding this form, please contact Jody Howatt at (503) 947-7699 or Dianna Janowski at (503) 947-7716.
Prepared by:
Telephone no.:
440-2937 (8/07/DCBS/WCD/WEB)
Return form to: Department of Consumer and Business Services
WCD/Compliance Section/Benefits and Certifications Unit
PO Box 14480
Salem, OR 97309-0405
2937
American LegalNet, Inc.
www.FormsWorkflow.com
