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Certification of Submitted Loss Data.pdf
Certification of Submitted Loss Data
This certificate must be submitted annually to certify the loss information is accurately reported.
11/3/2017 10:11 AMSystem Account
Data Reporting Instructions.pdf
Data Reporting Instructions
Data reporting requirements for loss report and simulated premium calculation report.
11/3/2017 10:12 AMSystem Account
Loss Report Enclosure A.xlsx
Loss Report Enclosure A
This is an example of how the loss report should look.
11/3/2017 10:12 AMSystem Account
Loss Report.xlsx
Loss Report
This is an example of how the loss report should look.  This version will assist in assuring that the claims in litigation status on 12/31/18 are meeting the Department of Workers' Claims (DWC) minimum indemnity reserve requirements.
11/7/2017 11:16 AMSystem Account
Payroll Enclosure E.xlsx
Payroll Enclosure E
This sheet must include quarterly payroll information for each self-insured entity.
11/3/2017 10:14 AMSystem Account
Self Insurance Package.pdf
Self Insurance Package
This package includes information and the necessary applications and forms for employers seeking certification as a self-insured entity.
2/24/2016 1:59 PMSystem Account
Simulated Premium Calculation.xls
Simulated Premium Calculation
This file will calculate the simulated premium by entering yearly loss and payroll totals in the proper cells.
11/3/2017 10:15 AMSystem Account