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
July 1, 2020 – December 31, 2020
1) * Insurer: «DBA»
Earned Premiums Information:
|(Please round all amounts to the nearest |Non-Mining: |Mining: |Total: |
|dollar) | | | |
| |(2) |(3) |(4) |
|July 1, 2020, through December 31, 2020 | | | |
|(Earned Premiums) | | | |
| |$________________ |$________________ |$________________ |
Claims Expenditure Information:
New: The insurer must submit claims information for each decertified self-insured employer or association of self-insured employers that this insurer has entered into or is a party to a loss portfolio transfer. Separate out the data below for claims expenditures under this insurer as a private carrier versus claims expenditures for each decertified self-insured employer or association of self-insured employers that this insurer assumed through a loss portfolio transfer. Place one decertified insurer on each line. Attach an additional sheet if more rows are needed.
| |(Please round all amounts to the |Non-Mining: |Mining: |Total: |
| |nearest dollar) | | | |
| | |(5) |(6) |(7) |
|Private Carrier Name: |July 1, 2020, through December 31, | | | |
|_____________ |2020 (For injuries on or after 7/1/99| | | |
| |for this insurer) |$_____________ |$_____________ |$_____________ |
|Decertified Self-Insured |July 1, 2020, through December 31, | | | |
|Employer Name: |2020 (For injuries on or after | | | |
|_____________ |7/1/99) for claims for a decertified |$_____________ |$_____________ |$_____________ |
| |self-insured employer assumed through| | | |
| |a loss portfolio transfer | | | |
|Decertified Association |July 1, 2020, through December 31, | | | |
|of Self Insurer Employers|2020 (For injuries on or after | | | |
|Name: _____________ |7/1/99) for claims for a decertified |$_____________ |$_____________ |$_____________ |
| |association of self-insured employers| | | |
| |assumed through a loss portfolio | | | |
| |transfer | | | |
(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: _________________________________________________
(10) Nevada Certificate of Authority Number: _____________________________________________
Please complete and return this form Compiled and approved on behalf of the above
No later than February 28, 2021, to: Insurer by:
Division of Industrial Relations ______________________________________
1830 College Pkwy, Suite 100 Insurer or Third-Party Administrator
Carson City, NV 89706
Attn: WCS Safety Assessment ______________________________________
Signature Date
Or at e-mail address
BI-fiscalunit@business. ______________________________________ Name (Please type or print) Phone #
*All fields must be filled out ______________________________________
Address of Intended Recipient
*Please see attached instructions
______________________________________ City, State, ZIP
______________________________________ Email
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- state of nevada department of education
- state of nevada cosmetology state board
- state of nevada division of real estate
- state of nevada board of nursing
- state of nevada board of medicine
- state of nevada secretary of state website
- state of nevada department of insurance
- state of nevada secretary of state search
- state of nevada secretary of state
- state of nevada division of insurance
- state of nevada board of nursing verification
- secretary of state of nevada forms