REPORT DUE DATE FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION BUREAU OF MONITORING AND AUDIT SELF-INSURANCE SECTION REPORT OF OUTSTANDING WORKERS' COMPENSATION LIABILITIES _____________________________________________________________________________________ INSTRUCTIONS: Report the outstanding reserves on all open claims incurred during the entire self-insurance period. Please include open claims for all companies covered under this self-insurance authorization and all other authorizations assumed by the self-insurer, but only those liabilities incurred in the State of Florida. Attach a loss run showing support for the above amounts detailed by claim. IF ANY OF THE INFORMATION ENTERED ON THE FORM IS ILLEGIBLE OR NOT IN COMPLIANCE WITH THE INSTRUCTIONS, THE FORM WILL BE RETURNED UNPROCESSED. NAME OF SELF-INSURER: FEIN NUMBER: EVALUATION DATE: CARRIER NUMBER: 999REPORTING PERIOD: I. TOTAL AMOUNT OF WORKERS' COMPENSATION LIABILITY A. REPORTED LOSSES B. PAID LOSSES C. OUTSTANDING LIABILITY (A-B) II. MONIES RECOVERABLE FROM THIRD PARTIES A. EXCESS INSURANCE B. SPECIAL DISABILITY TRUST FUND C. OTHER ____________________________________________ D. TOTAL AMOUNT RECOVERABLE (A+B+C) III. NET OUTSTANDING LIABILITY {I(C) - II(D)} REMARKS: REPORT COMPLETED BY NAME: COMPANY AND TITLE: ADDRESS: PHONE: DATE: Mail completed form to: FSIGA MEMBER: Florida Self-Insurers Guaranty Association, Inc., 1427 East Piedmont Drive, 2nd Floor, Tallahassee, Florida 32308. GOVERNMENTALS: Division of Workers' Compensation, Bureau of Monitoring and Audit, Self-Insurance Section, 200 East Gaines Street, Tallahassee, Florida 32399-4224. Form DFS-F2-SI-20 (8/2009) Rule 69L-5.207, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETION OF FORM DFS-F2-SI-20 REPORT OF OUTSTANDING WORKERS' COMPENSATION LIABILITIES IF ANY OF THE INFORMATION ENTERED ON THE FORM IS ILLEGIBLE OR NOT IN COMPLIANCE WITH THESE INSTRUCTIONS, THE FORM WILL BE RETURNED UNPROCESSED. Some lines are not covered in these instructions as the mathematical formulas and/or instructions are included on the form. If you have any questions concerning the form or these instructions, please contact_____________________________. NAME OF SELF-INSURER ­ This is the name of the authorization holder. FEIN ­ This is the Federal Employer Identification Number of the authorization holder. CARRIER NUMBER ­ This is the self-insured carrier number assigned to the authorization at the time it was approved. EVALUATION DATE ­ This is the authorization holder's most recent fiscal year end. REPORT DUE DATE ­ This is 120 days after the Evaluation Date. SECTION I, LINE A (Reported Losses) ­ This is the total dollar amount incurred (total payments + total reserves), as of the evaluation date, for all open claims with accident dates from the effective date of the self-insurance privilege through the date of the authorization holder's most recent fiscal year end. Do not include the total incurred amount for any closed claims. Claims included on this line are the only claims that can be considered on all other lines. SECTION I, LINE B (Paid Losses) ­ This line is the total dollar amount of all payments made on open claims reported in SECTION I, LINE A. SECTION II, LINE A (Excess Insurance Recoverable) ­Amount of outstanding liabilities (SECTION I, LINE C) estimated to be recoverable from excess carriers for payments not yet made. Do not include amounts due from excess carriers for reimbursement of amounts already paid by the self-insurer. Any amounts included on this line must be supported by a detailed listing of amounts by claim. SECTION II, LINE B (Special Disability Trust Fund Recoverable) ­ This is the total dollar amount of all Special Disability Trust Fund reimbursements offered to and accepted by the authorization holder, for payments not yet made. Do not include amounts due from the Special Disability Trust Fund for reimbursement of amounts already paid by the self-insurer. Any amounts included on this line must be supported by a detailed listing of amounts by claim. SECTION II, LINE C (Other Recoverable) ­ This is the total dollar amount known to be owed to the authorization holder from any source other than excess insurance or the Special Disability Trust Fund for payments not yet made. Any amounts included on this line must be supported by a detailed listing of amounts by claim. Form DFS-F2-SI-20 (8/2009) Rule 69L-5.207, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com