SURPLUS DISTRIBUTION REQUEST In order to receive authorization for a surplus distribution, the following form must be filled out and returned to: Self-Insurance Unit, Division of Workers' Compensation, POB 58, Jefferson City, MO, 65102. All surplus distributions must have prior authorization from the Division before disbursement. If you have questions, please call (573) 526-6021 for assistance. GROUP NAME:______________________________________________________ TERM:______________________________________________________________ AMOUNT OF SURPLUS DISTRIBUTION REQUESTED:__________________ 1. INCOME/REVENUE* _________________________ 2. PAID LOSSES _________________________ 3. RESERVES ** _________________________ 4. IBNR ** _________________________ 5. EXPENSES _________________________ 6. TAXES _________________________ 7. PRIOR SURPLUS DISTRIBUTION _________________________ (Subtract lines 2-7 from line 1 for total surplus) 8. TOTAL SURPLUS 9. # OF OPEN CLAIMS __________________________ _____________________ * Income/Revenue must be substantiated by an income statement. Please include with Summary. ** Reserves and IBNR must be substantiated by an actuarial study. Please include with Summary. 2000 © American LegalNet, Inc. 2000 © American LegalNet, Inc.