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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS COMPENSATION (To Be Filed By Self-Insured)

3315 WEST TRUMAN BLVD. P.O. BOX 58 JEFFERSON CITY, MO 65102-0058

STATEMENT OF SPECIFIC AND AGGREGATE EXCESS INSURANCE COVERAGE

Name of Approved Self-Insured: Other Named Insureds on Policy:

________________________________________ ________________________________________
(Please attach separate sheet if necessary)

Address of Self-Insured:

________________________________________ ________________________________________ ________________________________________ ________________________________________

Insurance Company Issuing Policy: ________________________________________ Policy No. _________________________ To remain in compliance with The Rules Governing Self-Insurance, the insurance company must: A. Be AM Best rated A- or better, B. Be an admitted carrier by the Missouri Department of Insurance, and C. Provide the division, by certified mail, notice of cancellation or nonrenewal sixty (60) days before actual termination. Named State: Missouri 1) Policy period: From: ____________________ To: 2) ____________________ ________________ ________________

Specific retention level: Each accident: Each employee for disease:

3)

Specific limit each accident: Policy Part One, Workers Compensation: Policy Part Two, Employers Liability:

____________________ ____________________ ___________________ ___________________

4)

Specific limit each employee for disease: Policy Part One, Workers Compensation: Policy Part Two, Employers Liability:

5)

Aggregate excess retention: Normal premium multiplied by: ________________ Minimum retention: ________________

6) 7)

Aggregate excess limit: __________________ Check here if aggregate excess coverage is not purchased. ________________

I swear the above information is true under penalty of perjury.
________________________________________________________________ Signature
(Representative of self-insured entity or insurance company only)

___________________________________ Date

___________________________________________________________________________________________________________ Company Name and Address
WC-121 (5-98) AI