Statement Of Specific And Aggregate Excess Insurance Coverage
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Statement Of Specific And Aggregate Excess Insurance Coverage Form. This is a Missouri form and can be use in Workers Comp.
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Tags: Statement Of Specific And Aggregate Excess Insurance Coverage, WC-121, Missouri Workers Comp,
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
STATEMENT OF SPECIFIC AND AGGREGATE
EXCESS INSURANCE COVERAGE
3315 West Truman Blvd.
P.O. Box 58
Jefferson City, MO 65102-0058
www.labor.mo.gov/DWC
(To Be Filed By Self-Insured)
Name of Approved Self-Insured:
Other Named Insureds on Policy:
________________________________________
________________________________________
(Please attach separate sheet if necessary)
________________________________________
Address of Self-Insured:
________________________________________
________________________________________
________________________________________
Insurance Company Issuing Policy: ________________________________________ Policy No. _________________________
To remain in compliance with The Rules Governing Self-Insurance, the insurance company must:
A. Be AM Best rated A- or better,
B. Be an admitted carrier by the Missouri Department of Insurance, and
C. Provide the division, by certified mail, notice of cancellation or nonrenewal sixty (60) days before actual termination.
Named State: Missouri
1) Policy period:
From: ____________________
To:
____________________
2) Specific retention level:
Each accident:
Each employee for disease:
___________________
___________________
3) Specific limit each accident:
Policy Part One, Workers’ Compensation: ____________________
Policy Part Two, Employers Liability:
____________________
4) Specific limit each employee for disease:
Policy Part One, Workers’ Compensation: ____________________
Policy Part Two, Employers Liability:
____________________
5) Aggregate excess retention:
Normal premium multiplied by: ___________________
Minimum retention:
___________________
6) Aggregate excess limit: ___________________
7) Check here if aggregate excess coverage is not purchased. __________________
I swear the above information is true under penalty of perjury.
_________________________________________________________________
Signature
____________________________________
Date
(Representative of self-insured entity or insurance company only)
____________________________________________________________________________________________________________
Company Name and Address
WC-121 (03-12) AI
American LegalNet, Inc.
www.FormsWorkFlow.com
