Free Form SI-08.xls - Kentucky

ENCLOSURE A

Form SI-08 Rev. 10/05 Employer Name:__________________ Loss Experience Report for Calendar Year(s):______________ NCCI Body Part and/or Indicator Nature of Injury Code

Social Security Number

Employee Employee Last First Name Name

Injury Date

OWC Agency Claim Number

Vocational Vocational Indemnity Medical Indemnity Medical Rehab. Rehab. Paid Reserve Reserve Paid as of Paid as of Reserve as as of as of as of 12/31/YR 12/31/YR of 12/31/YR 12/31/YR 12/31/YR 12/31/YR

SIR

* Please Total Each Individual Year