Statement Of Specific And Aggregate Excess Insurance Coverage {WC-121}

WC-121 - STATEMENT OF SPECIFIC AND AGGREGATE EXCESS INSURANCE COVERAGE. This form is used by self-insured entities in Missouri's Division of Workers' Compensation to provide information about specific and aggregate excess insurance coverage. It collects details about the entity's insurance policy, including coverage limits, deductibles, and policy periods. The form also outlines requirements for insurance companies to remain compliant with self-insurance rules. The form is signed by a representative of the self-insured entity or the insurance company, affirming the accuracy of the information provided. It ensures that self-insured entities have appropriate coverage for workers' compensation liabilities. www.FormsWorkflow.com