Follow the steps to successfully complete the form ID IC-211 online.

1. Click the ‘Get Form’ button to obtain the form and open it for editing.
2. Enter the name of the self-insured employer, the year, and select the appropriate semi-annual date in the heading section.
3. In Column 1, provide the total number of open claims as of the snapshot reporting date.
4. In Column 2, input the total incurred medical only liability, including all paid and anticipated unpaid liabilities.
5. In Column 3, enter the total dollar amount that has been paid on medical only claims reported in Column 2.
6. In Column 4, calculate the unpaid medical only amount by subtracting Column 3 from Column 2.
7. In Column 5, list the total incurred liability on all indemnity claims, including all paid and anticipated unpaid liabilities.
8. In Column 6, record the total dollar amount paid on all indemnity claims reported in Column 5.
9. In Column 7, calculate the unpaid indemnity amount by subtracting Column 6 from Column 5.
10. In Column 8, enter the total amount of unpaid liability for all medical only and indemnity claims by adding Column 4 and Column 7.
11. Under ‘Excess Insurance Carrier Reimbursement Expected’, indicate any expected reimbursement amount from an excess insurance policy related to Column 7.
12. Calculate and enter the net remaining unpaid liability by subtracting the excess carrier reimbursement from the unpaid liability.
13. If applicable, complete the excess carrier reimbursement detail section, listing each claimant along with the respective information.
14. Finally, sign and certify the form as a corporate officer and ensure that the preparer’s details are included.
15. Save the changes, download, and print the completed form for submission.

Complete your ID IC-211 form online today to ensure compliance and timely reporting.