Free SI-20 - Florida

STATE OF FLORIDA BUREAU OF MONITORING AND AUDIT
REPORT OF OUTSTANDING WORKERS' COMPENSATION LIABILITIES __________________________________________________________________________________ INSTRUCTIONS: This form must be returned with your Summary Loss Reports. Report the outstanding reserves on all open claims which you have incurred during the period that you have been self- insured in the state of Florida . Provide this information through the end of the most recently completed policy year (same period as used on loss report number 1). Please show cumulative amounts for all subsidiary companies, and only those liabilities incurred in the state of Florida. List the outstanding liabilities by policy year on the back of this report. NAME OF SELF INSURER: FEIN NUMBER EVALUATION DATE __________________________________________________________________________________ I. TOTAL AMOUNT OF WORKERS' COMPENSATION LIABILITY: A. REPORTED LOSSES B. PAID LOSSES _____________________ _____________________

C. OUTSTANDING LIABILITY (A - B) __________________________________________________________________________________ II. RESERVES FOR LOSSES INCURRED BUT NOT REPORTED (Note: Estimate this amount for all claims. You should include any occupational disease exposure that you might have.) __________________________________________________________________________________ III. MONIES RECOVERABLE FROM THIRD PARTIES: A. EXCESS INSURANCE B. SPECIAL DISABILITY TRUST FUND C. OTHER _________________________________ _____________________ _____________________ _____________________

D. TOTAL AMOUNT RECOVERABLE (A + B + C) __________________________________________________________________________________ IV. NET OUTSTANDING LIABILITY {I(C) + II - III(D)} __________________________________________________________________________________ REMARKS:

__________________________________________________________________________________ REPORT COMPLETED BY: DATE: EMPLOYER NAME: __________________________________________________________________________________ Mail completed form to: Division of Workers' Compensation, Self-Insurance Section, 200 East Gaines Street, Tallahassee, FL 32399-4224 Form SI-20 (Rev 9/96)