Surplus Distribution Request
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Surplus Distribution Request Form. This is a Missouri form and can be use in Workers Comp.
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Tags: Surplus Distribution Request, WC-265, Missouri Workers Comp,
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
SURPLUS DISTRIBUTION REQUEST
3315 West Truman Blvd.
P.O. Box 58
Jefferson City, MO 65102-0058
573-526-3692
www.labor.mo.gov/DWC
In order to receive authorization for a surplus distribution, the following form must be
completed and returned to: Insurance Unit, Division of Workers’ Compensation (DWC),
P.O. Box 58, Jefferson City, MO 65102-0058. All surplus distributions must have prior approval
from the DWC before disbursement. If you have questions, please call 573-526-3692 for
assistance.
Group Trust Name __________________________________________________________________________
Term (Trust Year) ___________________________________________________________________________
Amount of Surplus Distribution Requested __________________________________________________
1. Premium Paid by Trust Members*
_____________________
2. Investment Income*
_____________________
3. Sum of 1 and 2*
_____________________
4. Losses and Loss Adjustment Expenses Paid
_____________________
5. Administrative Expenses
_____________________
6. Reserves**
_____________________
7. IBNR**
_____________________
8. Prior Surplus Distribution
_____________________
9. Sum of 4, 5, 6, 7, and 8
_____________________
10. Surplus Monies
_____________________
11. Surplus Monies Remaining after Surplus Distribution Requested
_____________________
12. Number of Open Cases
_____________________
* Premium paid by trust members and investment income must be supported by an attached income
statement.
** Reserves and IBNR must be accompanied by an actuarial opinion.
_________________________
(Completed By)
_________________________
(Date)
WC-265 (04-12) AI
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