STATE OF NEVADA
STATE OF NEVADA
Department of Business and Industry
Division of Industrial Relations
Summary of Premium Earned and Claims Expenditures
Workers’ Compensation Premiums Earned
And Workers’ Compensation Claims Expenditures
January 1, 2019 – June 30, 2019
1) * Insurer: «DBA»
Earned Premiums Information:
|(Please round all amounts to the nearest |Non-Mining: |Mining: |Total: |
|dollar) | | | |
| |(2) |(3) |(4) |
|January 1, 2019, through June 30, 2019 | | | |
|(Earned Premiums) | | | |
| |$________________ |$________________ |$________________ |
Claims Expenditure Information:
|(Please round all amounts to the nearest |Non-Mining: |Mining: |Total: |
|dollar) | | | |
| |(5) |(6) |(7) |
|January 1, 2019, through June 30, 2019 (For| | | |
|injuries on or after 7/1/99) | | | |
| |$________________ |$________________ |$________________ |
(8) Does this report include all entities covered under the Certificate of Insurance for the insurer listed above?
( ) YES ( ) NO
(9) Insurer’s Federal Tax I.D. Number: _________________________________________________
Please complete and return this form Compiled and approved on behalf of the above
No later than August 31, 2019, to: Insurer by:
Division of Industrial Relations ______________________________________
1830 College Pkwy, Suite 100 Insurer or Third-Party Administrator
Carson City, NV 89706
Attn: WCS Assessments ______________________________________
Signature Date
Or at e-mail address
BI-fiscalunit@business. ______________________________________ Name (Please type or print) Phone #
______________________________________
Address of Intended Recipient
*Please see attached instructions
______________________________________ City, State, ZIP
______________________________________ Email
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