ENCLOSURE A Form SI-08 Rev. 10/05 Employer Name:__________________ Loss Experience Report for Calendar Year(s):______________ Social Security Number Employee Employee Last First Name Name Injury Date NCCI Body Part and/or Indicator Nature of Injury Code OWC Agency Claim Number Vocational Vocational Indemnity Medical Indemnity Medical Rehab. Rehab. Paid Reserve Reserve Paid as of Paid as of Reserve as as of as of as of 12/31/YR 12/31/YR of 12/31/YR 12/31/YR 12/31/YR 12/31/YR SIR * Please Total Each Individual Year American LegalNet, Inc. www.USCourtForms.com