Skip Ribbon Commands
Skip to main content
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.
11/2/2016 2:58 PMSystem Account
Data Reporting Instructions.pdf
Data Reporting Instructions
Data reporting requirements for loss report and simulated premium calculation report.
11/2/2016 2:59 PMSystem Account
Loss Report Enclosure A.xlsx
Loss Report Enclosure A
This is an example of how the loss report should look.
11/4/2016 1:35 PMSystem 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 12/31/16 are meeting the Department of Workers' Claims (DWC) minimum indemnity reserve requirements.
11/3/2016 8:49 AMSystem Account
Payroll Enclosure E.xls
Payroll Enclosure E
This sheet must include quarterly payroll information for each self-insured entity.
11/2/2016 3:02 PMSystem 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.
11/2/2016 3:08 PMSystem Account