Unit Statistical Report {SI-17}

REPORT DUE DATE FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION BUREAU OF FINANCIAL ACCOUNTABILITY SELF-INSURANCE SECTION Page of Pages UNIT STATISTICAL REPORT REPORT NUMBER 12 3 SELF-INSURER'S NAME AND ADDRESS FEIN NUMBER CARRIER NUMBER 999BEGINNING DATE ENDING DATE ACCOUNT NUMBER IF ANY OF THE INFORMATION ENTERED ON THE FORM IS ILLEGIBLE OR NOT IN COMPLIANCE WITH THE INSTRUCTIONS, THE FORM WILL BE RETURNED UNPROCESSED. SOCIAL SECURITY STATUS INJURY PAYROLL DATE OF NO. OR NUMBER CODE CLASS ACCIDENT (EXCESS CLAIMS ONLY) OF CLAIMS CODE* EVALUATION DATE INCURRED LOSS MEDICAL INDEMNITY ENTER TOTAL ALLOCATED LOSS ADJUSTMENT EXPENSE INCURRED TOTALS $ ___________ $___________ *Only payroll classification codes shown on the self-insurer payroll report for the corresponding payroll period can be used on this form. REPORT COMPLETED BY: ___________________________________________________ (Print Name & Title): ___________________________________________________ (Company) ___________________________________________________ (Telephone) ___________________________________________________ (Signature) ___________________________________________________ (Address) ___________________________________________________ (City, State, Zip) PLEASE RETURN COMPLETED REPORT TO: FSIGA MEMBERS Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org FORM DFS-F2-SI-17 (11/2012) Rule 69L- 5.205, F.A.C American LegalNet, Inc. www.FormsWorkFlow.com GOVERNMENTALS Division of Workers' Compensation Bureau of Financial Accountability, Self-Insurance Section 200 East Gaines Street Tallahassee, Florida 32399-4221 http://www.myfloridacfo.com/WC/ INSTRUCTIONS FOR COMPLETION OF FORM SI-17 SELF-INSURER UNIT STATISTICAL REPORT IF ANY OF THE INFORMATION ENTERED ON THE FORM(S) IS ILLEGIBLE OR NOT IN COMPLIANCE WITH THESE INSTRUCTIONS, THE FORM(S) WILL BE RETURNED UNPROCESSED. These instructions are to clarify the completion of the form(s). Some lines are not covered in these instructions as the instructions are included on the form. Reports must be submitted for the last three policy periods or back to the effective date of the self-insurance privilege, if the effective date is less than three policy periods back. If you have any questions concerning the form or these instructions, please contact Debra Compton at (850) 222-1882. NAME OF SELF-INSURER ­ This is the name of the authorization holder. FEIN ­ This is the Federal Employer Identification Number of the authorization holder. CARRIER NUMBER ­ This is the self-insured carrier number assigned to the authorization at the time it was approved. BEGINNING DATE ­ This is the first day of the period corresponding to the report number marked. ENDING DATE ­ This is the last day of the period corresponding to the report number marked. EVALUATION DATE ­ This is six months after the authorization holder's most recent anniversary rating date. REPORT DUE DATE ­ This is two months after the evaluation date. REPORT NUMBER ­ Mark Report 1, if this report covers claims for the most recently ended policy period. Mark Report 2, if this report covers the previous period (this period would have been Report 1 at the time of the last submission). Mark Report 3, if this report covers the period before the previous period (this period would have been Report 2 at the time of the last submission). Be sure to indicate the number of pages in each report. CLAIM NUMBER OR NUMBER OF CLAIMS COLUMN­ For an excess claim (over $10,000), this is the claim number assigned to this claim by either you or your servicing entity. For non-excess claims ($10,000 or less), this is the number of claims in the group. Non-excess claims must be grouped by injury code, payroll classification code and status. STATUS COLUMN ­ This is "0" (zero) for open claims (payments are currently being made and/or anticipated to be made in the future) and "1" (one) for closed claims (final payment has been made, but may reopen if it is later determined that additional payments need to be made). INJURY CODE COLUMN ­ This is the appropriate NCCI "Workers' Compensation Statistical Plan Manual" (which may be obtained from the National Council on Compensation Insurance, Boca Raton, Florida) injury code from the list below and indicates the type of injury: a) DEATH ­ Code "1". The amount entered as indemnity must include all paid and outstanding benefits including compensation paid to the deceased prior to death and burial expenses. b) PERMANENT TOTAL DISAABILITY ­Code "2". Applies to all claims that have been adjudicated permanent total, are defined under law as permanent total, or, in the self-insurer's judgment, will result in permanent total disability. c) IMPAIRMENT BENEFITS (Prior to July 1, 2010) ­ Code "3". Impairment benefit claims may be reported with injury type code 03 or 09 for claims reported with a Policy effective date prior to July 1, 2010. For impairment benefit claims with a policy effective date of July 1, 2010, and subsequent, the injury type code must be reported as 09. Concurrently, injury type 03 must not be reported for impairment benefit claims with a policy effective date of July 1, 2010 and subsequent. FORM DFS-F2-SI-17 (11/2012) Rule 69L- 5.205, F.A.C American LegalNet, Inc. www.FormsWorkFlow.com d) SUPPLEMENTAL BENEFITS ­ Code "4". Applies to all claims occurring prior to October 1, 2003, where payment of benefits follows the expiration of scheduled impairment benefits on permanent partial claims payable under Section 440.15(3), F.S. e) TEMPORARY INJURY ­ Code "5". Applies to all claims for which indemnity benefits have been paid or are expected to be paid, but which do not involve death, permanent total disability, wage loss benefits, or impairment benefits. f) MEDICAL ONLY CLAIMS ­ Code "6". Applies to all claims for which only medical benefits have been paid. Enter zero in the indemnity column. g) CONTRACT MEDICAL ­ Code "7". Applies to contract medical costs that cannot be allocated to individual claims. Enter the aggregate amount of medical benefits in the medical column and enter zero in the indemnity column. Contract medical costs reported must be the actual costs incurred. Contract medical cost allocated to the individual claims must be reported with those claims and cannot be coded "7". h) IMPAIRMENT BENEFITS (after July 1, 2010) ­ Code "9". Impairment benefit claims may be reported with inju