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