(7) Page of Pages SELF-INSURANCE UNIT STATISTICAL REPORT (NEW APPLICANT) REPORT NO. (1) 1 [ ] 2 [ ] 3 [ ] EMPLOYER NUMBER ACCOUNT NUMBER BEGINNING DATE ENDING DATE (2) (3) (4) (5) _________________________________________________________________________________________ EMPLOYER NAME (s) (6) SOCIAL SECURITY NO. OR NUMBER OF CLAIMS (8) STATUS (9) INJURY CODE (10) PAYROLL CLASS CODE (11) DATE OF ACCIDENT (EXCESS CLAIMS ONLY) (12) TOTALS ENTER BELOW TOTAL ALLOCATED LOSS ADJUSTMENT EXPENSE INCURRED INCURRED LOSS _ MEDICAL (13) INDEMNITY (14) (15) (15) REPORT COMPLETED BY: (16) PLEASE RETURN COMPLETED REPORT TO: SELF-INSURANCE SECTION P. O. Box 5497 TALLAHASSEE, FL 32314-5497 FORM SI-17 New Applicant (9/96) Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR COMPLETING THE SELF-INSURANCE UNIT STATISTICAL REPORT (FORM SI-17) General Instructions This report will be mailed to you on the 20th of the month before your evaluation date. It is due in our office two months after the evaluation date. Report all injuries with dates of accident between the beginning and ending dates for the report (inclusive). All information entered on the form must be legible (preferably typewritten). Specific Instructions Please refer to the corresponding numbers on the sample form attached. terms are attached to these instructions. Definitions of key (1) - (6) These items are completed by the Self-Insurance Section prior to mailing. (7) Indicate the number of pages in the report. (8) Enter the social security number of the claimant for an excess claim (over $5,000). Enter the number of claims in a group on non-excess claims ($5,000 or less). Non-excess claims must be grouped by injury code, payroll classification code and status. (9) Indicate the status of the claim (s). (one) for closed claims. (10) Enter ?0" (zero) for open claims and ?1" Enter the appropriate NCCI injury code (Ref. Pg. 3 & 4). (11) Enter the appropriate payroll classification code. Do not use classification codes that are not included in your payroll reports, as you cannot have a claim in a code that has no reported payroll. (12) For excess claims only, enter the date of accident. 01/01/97 or 01-01-97. (13) Enter the incurred medical cost. (14) Enter the incurred indemnity cost. Use the following format: Use whole dollars only. Use whole dollars only. (15) Enter the total incurred medical and incurred indemnity. than one page, enter the totals only on the last page. (16) period. (No cents). (No cents) If your report is more Enter the total allocated loss adjustment expense incurred during the reporting If the report is more than one page, enter the total on the last page only. NOTE: Failure to unacceptable report. comply with the above specific instructions will result in an DEFINITIONS ALLOCATED LOSS ADJUSTMENT EXPENSE Expenses such as attorneys? fee, legal expense, investigation cost, witness fees, court costs, documents cost and other expenses directly related and allocated to the cost of settling a specific claim. DO NOT include unallocated loss adjustment expenses, i.e., expenses which are not directly assignable to a particular claim. Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com DATE OF ACCIDENT Accident dates for injuries on a given report shall fall between the beginning and ending dates of the specific report, even if the accident date of the injury is not reported (i.e., nonexcess claims). EXCESS CLAIMS: (Ref. p. 17 WCSP)* Claim where the total incurred loss is greater than $5,000.00. INCURRED LOSS: (Ref. p. 60, WCSP)* The total dollar amount which the self-insurer expects to pay to the conclusion of the case and includes both payments already made and outstanding reserves. Incurred losses shall exclude attorney fees awarded due to "bad faith" on the part of the self-insurer, pursuant to Section 440.34, Florida Statutes. INDEMNITY: (Ref. p. 17 WCSP)* Vocational rehabilitation cost and outstanding reserves for future compensation payments shall be included as part of the amount reported for indemnity. MEDICAL ON ALL COMPENSABLE CLAIMS: (Ref. p. 25 WCSP)* Opposite each type of compensable claim, enter the medical cost (paid plus outstanding reserves) in connection with such claim. Include all payments to doctors and hospitals as well as physical rehabilitation but do not include any claim expense. NCCI INJURY CODE: Indicates the kind of injury. (Ref. p. 62c WCSP and p. 18 & 19 WCSP)* a. DEATH: (Code #1) Amount entered as indemnity shall include all paid and outstanding benefits including compensation paid to the deceased prior to death; include burial expenses. b. PERMANENT TOTAL DISABILITY: (Code #2) Enter any claim which has been adjudged permanent total or which is defined under law as permanent total or which, in the self-insurer's judgment, will result in permanent total disability. ∗ UNIT STATISTICAL PLAN may be Insurance, Boca Raton, Florida. obtained through the National Council on Compensation c. WAGE-LOSS & NO IMPAIRMENT BENEFIT: (Code #3) Enter every case where wage loss benefits are paid or payable under Section 440.15(3), Florida Statutes, and no impairment benefit is paid or payable. The amount entered as indemnity shall include compensation for temporary disability. d. WAGE-LOSS & IMPAIRMENT BENEFIT: (Code #4) Enter every case where both wage-loss and impairment benefits are paid or payable under Section 440.15(3), Florida Statutes. Include compensation for temporary total disability. The amount entered as indemnity shall include compensation for temporary disability. e. TEMPORARY TOTAL OR TEMPORARY PARTIAL BENEFITS: (Code #5) Enter every case which involves or is expected to involve indemnity benefits but which do not constitute a case of death, permanent total, wage-loss or impairment benefits. f. MEDICAL ONLY CLAIMS: g. CONTRACT MEDICAL: (Code #7) Contract medical costs which cannot be allocated to individual claims shall be reported in the aggregate in the "Medical" column. Enter zero (0) under indemnity and use Code #7. Such medical shall be assigned to the governing payroll class code. Contract medical cost allocated to the individual claims shall be reported in connection with these claims and shall not be coded "7". Amounts reported shall be the actual cost incurred. Page 3 of 4 (Code #6) Enter zero (0) under indemnity and use Code #6. American LegalNet, Inc. www.FormsWorkflow.com h. IMPAIRMENT BENEFIT & NO WAGE-LOSS BENEFIT: (Code #9) Enter every case where impairment benefits are paid or payable and no wage-loss benefits are paid or payable under Section 440.15(3), Florida Statutes. i. HOSPITAL ALLOWANCE: j. MEDICAL OR LEGAL EXPENSE: Medical or legal expense incurred for the benefit of the selfinsurer to secure evidence before a Deputy Commissioner or court shall be treated as adjusting expenses. NOTE: Where the claimant calls the attending physician to give medical testimony on his behalf or where the self-insurer is required to produce the claimant's physician at the hearing and is required to pay such a physician's fee, the payment of the fee shall be reported as a medical loss. When an award to a claimant includes the cost of witness fees, attorneys? fees (other than "bad faith") and other court costs, the amount so awarded shall be included as part of the indemnity benefit. Not applicable to self-insurers. NON-EXCESS CLAIMS All claims other than excess claims. OUTSTANDING RESERVES Incurred loss less amounts paid as of a specified date. Also, known as reserves. PAYROLL CLASSIFICATION CODE: Use the code to which the claim has been assigned. Report the code corresponding to the classification determined according to the NCCI rules and reported to the Bureau of SelfInsurance on Form BSI-5. No claims may be assigned to any classification unless payroll has been reported for that class. PHYSICAL REHABILITATION (MEDICAL) Medical or other treatment provided under the direct supervision or instruction of a physician for the purpose of restoring or improving the physical and mental abilities of the injured worker in order to maximize self-sufficiency and independence. This would include psychiatric and psychological testing. RESERVES See Outstanding Reserves. STATUS-CLOSED Indicates that the final payment has been made. payments are to be made. Closed cases may be reopened if additional STATUS-OPEN As of a specified date, statutory benefit payments are being made or anticipated to be made in the future. VOCATIONAL REHABILITATION (INDEMNITY) Training, counseling, evaluation or other services provided a claimant for the express purpose of allowing the injured worker to resume gainful employment. This would include aptitude and similar testing. Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com