Self Insurer Report Of Losses Non Experience Rating Period
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Self Insurer Report Of Losses Non Experience Rating Period Form. This is a Oregon form and can be use in Self Insured Employer Workers Comp.
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Tags: Self Insurer Report Of Losses Non Experience Rating Period, 2810, Oregon Workers Comp, Self Insured Employer
Self-Insurer Report of Losses
Non-Experience Rating Period
Workers’ Compensation Division
Page 1 of
Period covered:
to
Valuation date: January 1,
Self-insurer name:
In accordance with OAR 436-050, all self-insured employers are required to submit claims loss data to the department for calculation of security deposit. The following
information must be submitted by March 1:
All claims with dates of injury prior to the experience rating period that have outstanding reserves as of January 1 must be reported. Attach the required PTD/Fatal Claim
Reserve Worksheets. See instructions relating to the submission of these worksheets.
Worker’s name
Date of
injury
Claim no.
Total
paid (a)
Outstanding
reserves (b)
Total incurred
losses (a+b)
CAT, SIR,
WDP, PTD, F,
rd
nd
3 , 2 injury
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Totals, this page:
$0.00
$0.00
$0.00
Totals from Page 2:
$0.00
$0.00
$0.00
$0.00
Totals from additional pages:
$0.00
Totals for above year: # of claims
$0.00
$0.00
(Include total number of claims from attached pages)
Ref: Bulletin 209
440-2810 (8/07/DCBS/WCD/WEB)
2810
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Self-Insurer Report of Losses, Non-Experience Rating Period
Worker’s name
Date of
injury
Claim no.
Total
paid (a)
Page 2 of
Outstanding
reserves (b)
Total incurred
losses (a+b)
CAT, SIR,
WDP, PTD, F,
rd
nd
3 , 2 injury
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Totals (transfer to Page 1):
$0.00
$0.00
$0.00
440-2810 (8/07/DCBS/WCD/WEB)
American LegalNet, Inc.
www.FormsWorkflow.com
