Issued by MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS, DIVISION OF WORKERS' COMPENSATION SELF-INSURER'S STATEMENT OF OUTSTANDING LOSSES Note - Include all open cases including all med only. Indicate PTD or Death Claims PTD = PTD D = Death Average Weekly Wage at the Time of the Accident Probable Future Duration In Weeks Page Date of Accident or Death 1 of Excess Carrier Paying on Claims (Y/N) State Injury Number Name of Insured or Deceased Weekly Compensation Nature of Injury Estimated Total Future Payments F = Final Award E = Estimate State OF County OF , being duly sworn, says that he/she is the (Name) (Title) Page Total or Grand Total (Grand Total Required) Total of All Pages of (Employer's Legal Name) $ $ Notary Seal or Stamp - . the employer that is responsible for death benefits or workers' compensation benefits due under the Missouri Workers' Compensation Law Chapter 287 RSMo and rules applicable thereto; that the foregoing statement is true to the best of his/her knowledge information and belief after careful investigation and examination of the employer s books; that it comprises all claims for death benefits and employer's knowledge, for workers' compensation benefits now existing against said employer so far as he/she knows or has been able after diligent inquiry to find out, and that the ages of claimants, the amounts payable per week and the nature of disability, are in each instance correctly stated so far as possible from information at hand and that the estimated probable duration of disability is based upon a careful review of each individual case within two weeks of signing this form. Sworn to me, this Day of Year Employer Signature Notary Signature WC-83 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com NOTE - Self-insurers must include on this form every outstanding claim whether or not an award has been made. Make notation as to the disposition of any death or disability case previously reported and omitted from this report. This report to be executed in the name of the self-insured firm or individual. SELF-INSURER'S STATEMENT OF OUTSTANDING LOSSES (Continued) Note - Include all open cases including all med only. Indicate PTD or Death Claims PTD = PTD D = Death Average Weekly Wage at the Time of the Accident Probable Future Duration In Weeks Page Date of Accident or Death 2 of Excess Carrier Paying on Claims (Y/N) State Injury Number Name of Insured or Deceased Weekly Compensation Nature of Injury Estimated Total Future Payments F = Final Award E = Estimate Page Total or Grand Total (Grand Total Required) $ - WC-83-2 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com SELF-INSURER'S STATEMENT OF OUTSTANDING LOSSES (Continued) Note - Include all open cases including all med only. Indicate PTD or Death Claims PTD = PTD D = Death Average Weekly Wage at the Time of the Accident Probable Future Duration In Weeks Page Date of Accident or Death 3 of Excess Carrier Paying on Claims (Y/N) State Injury Number Name of Insured or Deceased Weekly Compensation Nature of Injury Estimated Total Future Payments F = Final Award E = Estimate Page Total or Grand Total (Grand Total Required) $ - WC-83-3 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com SELF-INSURER'S STATEMENT OF OUTSTANDING LOSSES (Continued) Note - Include all open cases including all med only. Indicate PTD or Death Claims PTD = PTD D = Death Average Weekly Wage at the Time of the Accident Probable Future Duration In Weeks Page Date of Accident or Death 4 of Excess Carrier Paying on Claims (Y/N) State Injury Number Name of Insured or Deceased Weekly Compensation Nature of Injury Estimated Total Future Payments F = Final Award E = Estimate Page Total or Grand Total (Grand Total Required) $ - WC-83-4 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com SELF-INSURER'S STATEMENT OF OUTSTANDING LOSSES (Continued) Note - Include all open cases including all med only. Indicate PTD or Death Claims PTD = PTD D = Death Average Weekly Wage at the Time of the Accident Probable Future Duration In Weeks Page Date of Accident or Death 5 of Excess Carrier Paying on Claims (Y/N) State Injury Number Name of Insured or Deceased Weekly Compensation Nature of Injury Estimated Total Future Payments F = Final Award E = Estimate Page Total or Grand Total (Grand Total Required) $ - WC-83-5 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com SELF-INSURER'S STATEMENT OF OUTSTANDING LOSSES (Continued) Note - Include all open cases including all med only. Indicate PTD or Death Claims PTD = PTD D = Death Average Weekly Wage at the Time of the Accident Probable Future Duration In Weeks Page Date of Accident or Death 6 of Excess Carrier Paying on Claims (Y/N) State Injury Number Name of Insured or Deceased Weekly Compensation Nature of Injury Estimated Total Future Payments F = Final Award E = Estimate Page Total or Grand Total (Grand Total Required) $ - WC-83-6 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com SELF-INSURER'S STATEMENT OF OUTSTANDING LOSSES (Continued) Note - Include all open cases including all med only. Indicate PTD or Death Claims PTD = PTD D = Death Average Weekly Wage at the Time of the Accident Probable Future Duration In Weeks Page Date of Accident or Death 7 of Excess Carrier Paying on Claims (Y/N) State Injury Number Name of Insured or Deceased Weekly Compensation Nature of Injury Estimated Total Future Payments F = Final Award E = Estimate Page Total or Grand Total (Grand Total Required) $ - WC-83-7 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com SELF-INSURER'S STATEMENT OF OUTSTANDING LOSSES (Continued) Note - Include all open cases including all med only. Indicate PTD or Death Claims PTD = PTD D = Death Average Weekly Wage at the Time of the Accident Probable Future Duration In Weeks Page Date of Accident or Death 8 of Excess Carrier Paying on Claims (Y/N) State Injury Number Name of Insured or Deceased Weekly Compensation Nature of Injury Estimated Total Future Payments F = Final Award E = Estimate Page Total or Grand Total (Grand Total Required) $ - WC-83-8 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com