WC-135 (12-18) AI 2018 Workers222 Compensation Trust Self-Insurance Annual Reporting Missouri Division of Workers222 Compensation is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. TDD/TTY: 800-735-2966 Relay Missouri: 711 American LegalNet, Inc. www.FormsWorkFlow.com WC-135-2 (12-18) AI MEMORANDUM TO: Self-Insurance Group Trust Administrators FROM: Missouri Division of Workers222 Compensation 226 Insurance Unit SUBJECT: Workers222 Compensation Group Trust Self-Insurance Annual Reporting 2018 Annual Report for Self-Insured Trusts In keeping with the Rules Governing Self-Insurance, 8 CSR 50-3.010 (6)(A), self-insured group trusts need to complete the enclosed 2018 Annual Report for Self-Insured Trusts WC-135 form [8 pages] and provide the following information to the Division of Workers222 Compensation (Division): a) General Information b) Trustee Information c) Calendar Year Data d) Cash and Investments as of December 31, 2018 e) Incurred But Not Reported (IBNR) Surplus Report f) Claim Development Report All group trusts, active and terminated, must complete the WC-135 form as long as there are active claims. The information contained in this report is to be based on the 2018 calendar year. All Division forms are on our website at www.labor.mo.gov/DWC. The direct website to obtain this form is www.labor.mo.gov/sites/labor/files/pubsforms/WC-135-AI.pdf. Please note that the Division now has a new way to submit the WC-135 form via an electronic mail box (Box). There is no cost to the trust associated with setting up a Box account. The Instructions for setting up a Box account are indicated below: 1) Send an email to Trusts@labor.mo.gov. Please include all authorized email addresses for the Trust to be allowed access to upload and download the filings, electronically to the Division. 2) You will receive an invitation to create your Box account for each email submitted. The invite will come from Ronette Applegate inviting you to collaborate on Box. Please accept the invite that appears below the name of your Trust. 3) Once the Box account is created, you will be granted authority to upload and download the filings you are submitting into your Trust folder. You have the option of submitting the completed WC-135 form to the Division of Workers222 Compensation via Box or by mail to P.O. Box 58, Jefferson City, MO 65102-0058 This form must be completed and returned to our office by May 31, 2019. Additionally, note the Rules Governing Self-Insurance 8 CSR 50-3.010 (6)(A)1, require group trusts to file annual financial reports within 150 days after the close of the trust222s fiscal year. The documentation or reports that need to be submitted annually and quarterly to the Division are available on our website. The Division continues to conduct audits relating to safety, claims and any other audits deemed necessary and appropriate by the Division as provided in 8 CSR 50-3.010 (9)(A). The Division has enjoyed working with you during the past year, and we look forward to continued success for the upcoming year. Should you have any questions or need any assistance regarding the above information, please contact the Insurance Unit at 573-526-6021. Enclosures American LegalNet, Inc. www.FormsWorkFlow.com WC-135-3 (12-18) AI GENERAL INFORMATION 1. GROUP TRUST Name of Group Trust or Other Group Self - Insured Executive Director ( if applicable ) P hone Number Address City, State, Z IP Code Type of Group Trust (heterogeneous, homogeneous, or Chapter 537) Broker (if applicable) 2. SPONSORING ASSOCIATION ( If A pplicable ) Name of Sponsoring Association Address City, State, Z IP Code 3. PLAN ADMINISTRATOR Name of Plan Administrator P hone Number Contact Name and Title E mail Address City, State, Z IP Code Location of Books & Claim Records 4. CLAIMS ADMINISTRATOR Name of Claims Administrator P hone Number Contact Name and Title E mail Address City, State, Z IP Code 5. ACTUARIAL INFORMATION Name of Actuary P hone Number Contact Name E mail Address City, State, Z IP Code 6. CERTIFIED PUBLIC ACCOUNTANT INFORMATION Name of Certified Public Accountant P hone Number Contact Name E mail Address City, State, Z IP Code 7. SAFETY (In house contact) Name of Safety Manager/Administrator Telephone Number E mail Address City, State, Z IP Code Do you use an outside safety consultant? Yes No (If 223Yes,224 please complete the following information. ) Name of Safety Consultant P hone Number E mail Address City, State, ZIP Code American LegalNet, Inc. www.FormsWorkFlow.com WC-135-4 (12-18) AI TRUSTEE INFORMATION BOARD OF TRUSTEES The Rules Governing Self-Insurance, 8 CSR 50-3.010 (7), require the board of trustees to have at least five (5) persons elected from membership of the trust, association, or organization for stated terms of office, to direct the administration of the trust. Please provide information for trustees. Name of Trustee /Chairperson E mail Member Affiliation Phone Number Address City, State, ZIP Code Name of Trustee /Vice - Chairperson E mail Member Affiliation Phone Number Address City, State, ZIP Code Name of Trustee /Secretary E mail Member Affiliation Phone Number Address City, State, ZIP Code Name of Trustee /Treasurer E mail Member Affiliation Phone Number Address City, State, ZIP Code Name of Trustee E mail Member Affiliation Phone Number Address City, State, ZIP Code Name of Trustee E mail Member Affiliation Phone Number Address City, State, ZIP Code Name of Trustee E mail Member Affiliation Phone Num ber Address City, State, ZIP Code Please attach additional pages if there are more trustees on the Board of Directors. Make sure to include all of the information above for each additional trustee. American LegalNet, Inc. www.FormsWorkFlow.com WC-135-5 (12-18) AI CALENDAR YEAR DATA As of 12-31-2018 1.REPORTING YEAR 2018 SURPLUS ESTIMATEAs of 12-311Earned Annual Premium2 Claims Paid (for injuries with dates of injury within the calendar year) Claims Reserves (for injuries with dates of injury within the calendar year) Incurred But Not Reported (IBNR) (for injuries with dates of injury within the calendar year) Total Administrative Expenses Including Taxes Estimated Surplus3 2.MISCELLANEOUS INFORMATIONAs of 12-31 Total Number of Trust Members Total Number of Employees of Current Trust Members Average Monthly Payroll of Trust Members Loss Ratio4 Administrative Expense Ratio Estimated Premium if Insured on Open Market Federal Employers Identification Number (FEIN)5 1 Will require conversion if fiscal year is not a calendar year. 2 Earned Annual Premium (EAP) 226 EAP is computed by applying the appropriate payroll code classification rates to the trust member222s annual payroll and multiplying the results by the experience modification factors of the trust members as developed by the advisory organization approved by the Department of Insurance and including any other discounts and surcharges. 3 Earned Annual Premium minus Claims Paid minus Claims Reserves minus Incurred But Not Reported (IBNR) minus Total Administrative Expenses Including Taxes should equal Estimated Surplus. 4 Loss Ratio 226 Total sum of claims paid and claims reserves and dividing the results by earned annual premium. 5Federal Employer Identification Number (FEIN) 226 If your trust has not obtained a FEIN, please state 223n/a224. American LegalNet, Inc. www.FormsWorkFlow.com WC-135-6 (12-18) AI CASH & INVESTMENTS as of 12-31-2018 The Rules Governing Self-Insurance 8 CSR 50-3.010 (7)(B) limit the type of investment activity for self-insured trusts to: U.S. Treasury Bills, Notes or Bonds, Certificates of Deposits issued by a duly chartered commercial bank, or a transaction account of the designated depository. Please complete the following investment schedule: INVESTMENT SCHEDULE Investment Type Purchase Price Current Fair Market Value U.S. Treasury Bills U.S. Treasury Bonds U.S. Notes Certificates of Deposits Total Upon Division approval, Chapter 287.280.6 RSMo permits up to 100 percent of surplus money from a prior trust year to be invested in securities designated by the Office of State Treasurer as acceptabl