Fill and Sign the Unit Statistical Report Si 17pdf Fpdf DOC Docxflorida Form

FORM DFS-F2-SI-17 ( 11/2012) Rule 69L - 5.205, F.A.C FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION BUREAU OF FINANCIAL ACCOUNTABILITY SELF-INSURANCE SECTION Page of Pages UNIT STATISTICAL REPORT REPORT NUMBER 1 2 3 SELF -INSURER ’S NAME AND ADDRESS IF ANY OF THE INFORMATION ENTERED ON THE FORM IS ILLEGIBLE OR NOT IN COMPLIANCE WITH T HE INSTRUCTIONS, THE FORM WILL BE RETURNED UNPROCESSED. SOCIAL SECURITY NO. OR NUMBER OF CLAIMS STATUS INJURY CODE PAYROLL CLASS CODE* DATE OF ACCIDENT (EXCESS CLAIMS ONLY) INCURRED LOSS MEDICAL INDEMNI TY TOTALS $ _ __________ $ ___________ * Only payroll classification codes shown on the self -insurer payroll report for the corresponding payroll period can be used on this form . REPORT COMPLETED BY : ___________________________________________________ (Print Name & Title ): ___________________________________________________ (Signature) ___________________________________________________ (Company) ___________________________________________________ (Address) ___________________________________________________ (Telephone) ______________________________________________ _____ (City, State, Zip) PLEASE RETURN COMPLETED REPORT TO: FSIGA MEMBERS GOVERNM ENT ALS Florida Self -Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222- 1882 www.fsiga.org Division of Workers’ Compensation Bureau of Financial Accountability , Self -Insurance Section 200 East Gaines Street Tallahassee, Florida 32399 -4221 http://www.myfloridacfo.com/WC/ FEIN NUMBER CARRIER NUMBER 999- BEGINNING DATE ENDING DATE ACCOUNT NUMBER EVALUATION DATE ENTER TOTAL ALLOCATED LOSS ADJUSTMENT EXPENSE INCURRED REPORT DUE DATE FORM DFS-F2-SI-17 ( 11/2012) Rule 69L - 5.205, F.A.C INSTRUCTIONS FOR COMPLETION OF FORM SI -17 SELF -INSURER UNIT STATISTICAL REPORT IF ANY OF THE INFORMATION ENTERED ON THE FORM(S) IS ILLEGIBLE OR NOT IN COMPLIANCE WITH THESE INSTRUCTIONS, THE FORM(S) WILL BE RETURNED UNPROCESSED. These instructions are to clarify the completion of the form(s). Some lines are not covered in these instructions as the instructions are included on the form. Reports must be submitted for the last three policy periods or back to the effective date of the self -insurance privilege , if the effective date is less than three policy periods back. If you have any questions concerning the form or these instructions, please contact Debra Compton at (850) 222 -1882. NAME OF SELF -INSURER – This is the name of the authorization holder. FEIN – This is the Federal Employer Identification Number of the authorization holder. CARRIER NUMBER – This is the self -insured carrier number assigned to the authorization at the time it was approved. BEGINNING DATE – This is the first day of the period co rresponding to the report number marked. ENDING DATE – This is the last day of the period corresponding to the report number marked. EVALUATION DATE – This is six months after the authorization holder’s most recent anniversary rating date. REPORT DUE DATE – This is two months after the evaluation date. REPORT NUMBER – Mark Report 1, if this report covers claims for the most recently ended policy period. Mark Report 2, if this report covers the previous period (this period would have been Report 1 at th e time of the last submission). Mark Report 3, if this report covers the period before the previous period (this period would have been Report 2 at the time of th e last submission). Be sure to indicate the number of pages in each report. CLAIM NUMBER OR NUMBER OF CLAIMS COLUMN– For an excess claim (over $ 10,000), this is the claim number assigned to this claim by either you or your servicing entity. For non -excess claims ($ 10,000 or less), this is the number of claims in the group. Non -excess claims must be grouped by injury code, payroll classification code and status. STATUS COLUMN – This is “0” (zero) for open claims (payments are currently being made and/or anticipated to be made in the future) and “1” (one) for closed claims (final payment has been made, but may reopen if it is later determined that additional payments need to be made). INJURY CODE COLUMN – This is the appropriate NCCI “Workers’ Compensation Statistical Plan Manual” (which may be obtained from the National Council on Compensation In surance, Boca Raton, Florida) injury code from the list below and indicates the type of injury: a) DEATH – Code “ 1”. The amount entered as indemnity must include all paid and outstanding benefits including compensation paid to the deceased prior to death an d burial expenses. b) PERMANENT TOTAL DISAABILITY – Code “2”. Applies to all claims that have been adjudicated permanent total, are defined under law as permanent total, or, in the self- insurer’s judgment, will result in permanent total disability. c) IMPAIRMEN T BENEFITS (Prior to July 1, 2010) – Code “3”. Impairment benefit claims may be reported with injury type code 03 or 09 for claims reported with a Policy effective date prior to July 1, 2010. For impairment benefit claims with a policy effective date of J uly 1, 2010, and subsequent, the injury type code must be reported as 09. Concurrently, injury type 03 must not be reported for impairment benefit claims with a policy effective date of July 1, 2010 and subsequent. FORM DFS-F2-SI-17 ( 11/2012) Rule 69L - 5.205, F.A.C d) SUPPLEMENTAL BENEFITS – Code “ 4”. Appl ies to all claims occurring prior to October 1, 2003, where payment of benefits follows the expiration of scheduled impairment benefits on permanent partial claims payable under Section 440.15(3), F.S. e) TEMPORARY INJURY – Code “ 5”. Applies to all claims for which indemnity benefits have been paid or are expected to be paid, but which do not involve death, permanent total disability, wage loss benefits, or impairment benefits. f) MEDICAL ONLY CLAIMS – Code “ 6”. Applies to all claims for which only medical benefits have been paid. Enter zero in the indemnity column. g) CONTRACT MEDICAL – Code “ 7”. Applies to contract medical costs that cannot be allocated to individual claims. Enter the aggregate amount of medical benefits in the medical column and enter zero in the indemnity column. Contract medical costs reported must be the actual costs incurred. Contract medical cost allocated to the individual claims must be reported with those claims and cannot be coded “7”. h) IMPAIRMENT BENEFITS (after July 1, 2010) – Code “9”. Impairment benefit claims may be reported with injury type code 03 or 09 for claims reported with a Policy effective date prior to July 1, 2010. For impairment benefit claims with a policy effective date of July 1, 2010, and subsequent, the in jury type code must be reported as 09. Concurrently, injury type 03 must not be reported for impairment benefit claims with a policy effective date of July 1, 2010 and subsequent. i) HOSPITAL ALLOWANCE – This code is not applicable to self -insurers. j) MEDICAL OR LEGAL EXPENSE – Medical or legal expense incurred for the benefit of the self -insurer to secure evidence before a Judge of Compensation Claims or court shall be treated as adjusting expense, except as noted: a. When the claimant calls the attending physician to give medical testimony on his behalf or where the self- insurer is required to produce the claimant’s physician at the hearing and is required to pay such a physician’s fee, the payment of the fee must be reported as a medical expense. b. When an award to a claimant includes the cost of witness fees, attorneys fees (other than “bad faith”) and other court costs, the amount so awarded must be included as part of the indemnity benefit. PAYROLL CLASS CODE COLUMN – This is the appropriate payroll clas sification code for a claim or group of claims as reported on the Self- Insurer Payroll Report for the same policy period. The use of any other classification codes is incorrect as it is not possible to have a claim in a class code that has no reported pay roll. DATE OF ACCIDENT (EXCESS CLAIMS ONLY) COLUMN – Accident dates for all accidents included on the report, excess and non -excess, must be between the beginning and ending dates shown on the respective report. Only use one of the following formats: xx /xx/xx or xx-xx -xx. INCURRED LOSS COLUMNS – Incurred loss is the total dollar amount that is paid on a claim until it is closed and includes both payments already made and outstanding reserves (payments anticipated to be made in the future). Incurred losses exclude attorney fees awarded due to “bad faith” on the part of the self -insurer, pursuant to Section 440.34, F.S. Only use whole dollars, no cents, in both the medical (payments to doctors, hospitals, and pharmacies as well as for physical rehabil itation and psychiatric and psychological testing and treatment, but not claim expense, must be included as part of the amount reported for medical) and indemnity (payments for vocational rehabilitation, including training, counseling, evaluation and aptit ude and similar testing to enable the claimant to resume gainful employment, as well as bi - weekly compensation payments must be included as part of the amount reported for indemnity) columns and total each column as indicated. If the report is more than one page, enter these totals only on the last page. TOTAL ALLOCATED LOSS ADJUSTMENT EXPENSE INCURRED– This is expenses such as attorney’s fees, legal expense, investigation cost, witness fees, court costs, document costs, and other expenses directly relat ed and allocated to the cost of settling a specific claim. Do not include unallocated loss adjustment expenses, which are those expenses that cannot be directly assigned to a particular claim.