Report of Paid Compensation and Case Reserves Company name Number of Ohio employees Self-Insuring policy number Please complete for calendar year ending Dec. 31, ______ Consolidate the corporate location and all subsidiaries on one report. Number of claims reported (regardless of their current disposition) A. Lost time (eight or more calendar days off work) B. Medical only (seven or fewer calendar days off work) C. Occupational disease D. Death E. Total List compensation payments made Type 1. (4123.56A) Temporary total 2. (4123.56) Wages in lieu of compensation 3. (4123.56A) Sick and accident benefits 4. (4123.56B) Wage loss 5. (4123.57A claims prior to 8/22/86) Temporary partial 6. (4123.57A; 4123.57B) % permanent partial 7. (4123.57B; 4123.57C) Scheduled loss awards 8. (4123.58) Permanent total 9. (4121.63) Living maintenance 10. (4123.67B) Living maintenance wage loss 11. (4123.59) Death 12. (4123.57D) Change of occupation 13. (4121.47) Violation of specific safety requirements 14. (4123.93 & 4123.512) Less subrogation/overturned claims/reimbursements 15. (Accurate reporting required by law) (Add lines #1 thru #13, Grand total of paid compensation Less line #14) 16. Total dollars paid to medical providers 17. Total benefits paid (Add lines #15 and #16) Total dollars paid $ ($ $ ($ ($ Amount ) Total open claims and case-reserves data (not covered by excess insurance) Pre-1987 1. Number of open medical-only claims 2. Number of open indemnity claims 3. Total outstanding case reserves for medical-only claims 4. Total outstanding case reserves for indemnity claims 1987 and post 1987 5. Number of open medical-only claims 6. Number of open indemnity claims 7. Total outstanding case reserves for medical-only claims 8. Total outstanding case reserves for indemnity claims BWC-7240 (Rev. 1/11/2011) Copy for employer records only - do not mail to BWC $ $ ($ ($ American LegalNet, Inc. www.FormsWorkFlow.com SI-40