Free SI-17 - Florida

Page SELF-INSURANCE UNIT STATISTICAL REPORT REPORT NO. 1 [ ] 2 [ ] 3 [ ] EMPLOYER NUMBER ACCOUNT NUMBER BEGINNING DATE ENDING DATE

of

Pages

_________________________________________________________________________________________ EMPLOYER NAME (s)

CLAIM NUMBER OR NUMBER OF CLAIMS

STATUS

INJURY CODE

PAYROLL CLASS CODE

DATE OF ACCIDENT (EXCESS CLAIMS ONLY)

INCURRED MEDICAL

LOSS

_

INDEMNITY

TOTALS

ENTER BELOW TOTAL ALLOCATED LOSS ADJUSTMENT EXPENSE INCURRED

REPORT COMPLETED BY:

PLEASE RETURN COMPLETED REPORT TO: Division of Workers' Compensation Bureau of Monitoring & Audit SELF-INSURANCE SECTION 200 E. Gaines St. TALLAHASSEE, FL 32399-4224 FORM SI-17 (1/2008)j:\siforms\wwm\si-17