Free WC-135 - Missouri


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Pages: 8
Date: April 24, 2009
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State: Missouri
Category: Workers Compensation
Author: DOLIR
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http://www.dolir.mo.gov/wc/forms/135-AI.pdf

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2008 WORKERS' COMPENSATION TRUST SELF-INSURANCE ANNUAL REPORTING

DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION

SELF-INSURANCE

WC-135 (04-09) AI

MEMORANDUM
TO: FROM: Self-Insurance Trust Administrators Paula Hinshaw Self-Insurance Financial Analyst II March 1, 2009 2008 Annual Report for Self-Insured Trusts

DATE: SUBJECT:

In keeping with the Rules Governing Self-Insurers 8 CSR 50-3.010 (6)(A), please complete the enclosed 2008 annual report for Self-Insured Trusts. All trusts, active and terminated, must complete this report as long as there are active claims. This report is to be based on the 2008 calendar year. All Division forms are now on our web site at www.dolir.mo.gov/wc. GOOD NEWS! The forms can now be filled out online. You may fill out the form online then print it off for mailing. The direct site is www.dolir.mo.gov/wc/forms/135-AI.pdf. Please complete the packet and submit to the Division of Workers' Compensation, P.O. Box 58, Jefferson City, MO 65102. This packet must be returned to our office by May 31, 2009. Additionally note that the Rules Governing Self-Insurers 8 CSR 50-3.010 (6)(A)1 require trusts to file annual financial reports within one hundred twenty (120) days after the close of the trust's fiscal year. The Division continues to conduct audits relating to safety, claims and any other audits deemed necessary and appropriate by the Division as provided in 8 CSR 50-3.010(9)(A). The Division has enjoyed working with you during the past year and we look forward to continued success for the upcoming year. Should you have any questions, or need any assistance regarding the above information, please contact us. Paula Hinshaw 573-526-6021 [email protected] Enclosures

WC-135-2 (04-09) AI

GENERAL INFORMATION
1. TRUST
Name of Trust Address Type of Trust: Homogeneous (Type) City, State, Zip Code Association

2. SPONSORING ASSOCIATION (IF APPLICABLE)
Name of Sponsoring Association Address City, State, Zip Code

3. PLAN ADMINISTRATOR
Name of Plan Administrator Contact Name Address Location of Books & Claim Records E-mail City, State, Zip Code Telephone Number

4. CLAIMS ADMINISTRATOR
Name of Claims Administrator Contact Name Address E-mail City, State, Zip Code Telephone Number

5. ACTUARIAL INFORMATION
Name of Claims Administrator Contact Name Address E-mail City, State, Zip Code Telephone Number

6. CERTIFIED PUBLIC ACCOUNTANT INFORMATION
Name of Claims Administrator Contact Name Address E-mail City, State, Zip Code Telephone Number

7. SAFETY MANAGER
Name E-mail Address City, State, Zip Code Telephone

WC-135-3 (04-09) AI

TRUSTEE INFORMATION
BOARD OF TRUSTEES
Chairman Address City, State, Zip Code Telephone Number

Vice Chairman Address City, State, Zip Code Telephone Number

Treasurer Address City, State, Zip Code Telephone Number

Secretary Address City, State, Zip Code Telephone Number

OTHER TRUSTEES
Trustee Name Trustee Name Trustee Name Trustee Name Trustee Name

WC-135-4 (04-09) AI

HISTORICAL DATA
1. FINANCIAL INFORMATION Earned Annual Premium Claims Paid Claims Reserves Incurred But Not Reported (IBNR) Total Administrative Expenses Including Taxes Level of Surplus As of 12-31-2008

2. MISCELLANEOUS INFORMATION Total Number of Current Members in the Trust Total Number of Current Employees in the Fund Average Monthly Payroll **Loss Ratio Administrative Expense Ratio Estimated Premium if Insured on Open Market ***Federal Employers Identification Number (FEIN)

As of 12-31-2008

*

Earned Annual Premium (EAP) EAP is computed by applying the appropriate payroll code classification rates to the trust member's annual payroll and multiplying the results by the experience modification factors of the trust members as developed by the advisory organization approved by the Department of Insurance and including any other discounts and surcharges. Loss Ratio Total sum of claims paid and claims reserves and dividing the results by earned annual premium.

**

*** Federal Employer Identification Number (FEIN) If your trust has not obtained a FEIN, please state "n/a".

WC-135-5 (04-09) AI

INVESTMENTS
The Rules Governing Self-Insurers 8 CSR 50-3.010 (7)(B) limit the type of investment activity for self-insured trusts to: United States treasury bills, notes or bonds, certificates of deposit issued by a duly chartered commercial bank, or a transaction account of the designated depository. Please complete the following investment schedule: INVESTMENT SCHEDULE
Investment Type U.S. Treasury Bills U.S. Treasury Bonds U.S. Notes Certificates of Deposits Total Purchase Price Current Fair Market Value

Upon Division approval, regulation (7)(D) permits 25% of surplus moneys from a prior trust year to be invested in securities designated by the Office of State Treasurer as acceptable collateral to secure state deposits pursuant to section 30.270.1, RSMo. Please complete the following investment schedule if your trust has invested in any securities not listed above. INVESTMENT SCHEDULE
Investment Type Purchase Price Current Fair Market Value

Total

You may attach an additional sheet if necessary.

WC-135-6 (04-09) AI

CLAIM DEVELOPMENT REPORT
CUMULATIVE PAID CLAIMS AND ALLOCATED EXPENSES AT YEAR END
Years in which claims were incurred Prior to 1999 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Total all years As of 12/31/1998 As of 12/31/1999 As of 12/31/2000 As of 12/31/2001 As of 12/31/2002 As of 12/31/2003 As of 12/31/2004 As of 12/31/2005 As of 12/31/2006 As of 12/31/2007 As of 12/31/2008

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CUMULATIVE RESERVES AT YEAR END
Years in which claims were incurred Prior to 1999 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Total all years As of 12/31/1998 As of 12/31/1999 As of 12/31/2000 As of 12/31/2001 As of 12/31/2002 As of 12/31/2003 As of 12/31/2004 As of 12/31/2005 As of 12/31/2006 As of 12/31/2007 As of 12/31/2008

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WC-135-7 (04-09) AI

INCURRED BUT NOT REPORTED (IBNR) AND SURPLUS REPORT
CUMULATIVE IBNR AT YEAR END
Years in which claims were incurred Prior to 1999 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Total all years As of 12/31/1998 As of 12/31/1999 As of 12/31/2000 As of 12/31/2001 As of 12/31/2002 As of 12/31/2003 As of 12/31/2004 As of 12/31/2005 As of 12/31/2006 As of 12/31/2007 As of 12/31/2008

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CUMULATIVE SURPLUS AT YEAR END
Years in which claims were incurred Prior to 1999 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Total all years As of 12/31/1998 As of 12/31/1999 As of 12/31/2000 As of 12/31/2001 As of 12/31/2002 As of 12/31/2003 As of 12/31/2004 As of 12/31/2005 As of 12/31/2006 As of 12/31/2007 As of 12/31/2008

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WC-135-8 (04-09) AI