Get Florida Self Insurer Unit Statistical Report Form

The Florida Self Insurer Unit Statistical Report Form is crucial for self-insurers to report their claims and financial activities accurately. This guide provides clear, step-by-step instructions to help users complete the form online with ease and confidence.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to access the report form and open it in your editing environment. This will allow you to fill out the necessary information digitally.
2. Begin by entering the self-insurer's name and address in the designated fields. Ensure that all information is clear and legible to avoid processing delays.
3. Input the Federal Employer Identification Number (FEIN) in the appropriate field. This number is essential for identifying the self-insurer.
4. Record the carrier number assigned to your self-insured status. This number will be available in your records from the approval process.
5. Fill in the beginning date and ending date for the reporting period. These dates should reflect the relevant policy period for which you are submitting the report.
6. Provide the evaluation date, which is typically six months from your most recent anniversary rating date. This date helps in understanding claim assessment timelines.
7. Select the report number that corresponds to the reporting period. Use 'Report 1' for the most recent period, 'Report 2' for the previous one, and 'Report 3' for the earlier period.
8. In the claims section, enter either the claim number for excess claims (over $5,000) or the number of claims for non-excess claims (up to $5,000) based on the organization of your data.
9. Indicate the status of each claim using '0' for open claims and '1' for closed claims. This helps to clarify the current state of your claims.
10. Input the appropriate injury code corresponding to each claim based on the type of injury as defined in the NCCI Workers’ Compensation Unit Statistical Plan Manual.
11. Specify the payroll class code for each claim, ensuring that it matches the classifications reported for the same policy period to maintain accuracy.
12. For excess claims only, record the date of the accident, ensuring that it falls within the beginning and ending dates specified in earlier sections.
13. Detail the incurred loss for both medical and indemnity in the respective columns. Use whole dollars and make sure to total these figures at the bottom of their respective sections.
14. Indicate the total allocated loss adjustment expenses incurred in the claims, differentiating them from unallocated expenses to maintain clarity in reporting.
15. Complete the form by filling in the print name, title, signature, company, address, telephone number, and city/state/zip in the specified fields.

Ensure that you complete and submit the Florida Self Insurer Unit Statistical Report Form online to stay compliant with reporting requirements.