commonwealth of virginia virginia …...self-insurance survey for 201: page 9 1 of 7. vwc form no....

Self-Insurance Survey for 2019: page 1 of 7. VWC Form No. SI 23A (Rev. 11/14/2017)

COMMONWEALTH OF VIRGINIA VIRGINIA WORKERS' COMPENSATION COMMISSION 1000 DMV DRIVE, RICHMOND VA 23220 ANNUAL SURVEY OF INDIVIDUAL SELF-INSURERS

January 7, 2019

Self-Insurance Number: ___________________________ Self-Insured Company Name: ___________________________ 2019 Update to Virginia Workers' Compensation Commission Records In order to update Commission records, we are asking you to provide the following information to us. This information is essential in ensuring that the Commission meets its responsibilities under Virginia law for the certification of individual self-insurers for workers' compensation. Once you have completed the survey, check off the lines below, sign and date this top sheet, and return the survey and the necessary additional materials by March 4, 2019 to Self-Insurance Program, Attn: Mechelle Esparza-Harris, Insurance Financial Examiner, Virginia Workers' Compensation Commission, 333 E. Franklin Street, Richmond, Virginia 23219 or by e-mail to [email protected]. If you have any questions, please contact Mechelle Esparza-Harris at (804) 205-3599 or at [email protected] or Brandy Giles at (804) 205-3113 or at [email protected].

_____ The survey is completed and enclosed. _____ A copy of the current excess insurance certificate is enclosed. The certificate

displays the sixty (60) day advance notice of cancellation condition (if provided earlier, give date mailed).

_____ All claims information is completed. For claims of $100,000, information should

include: • Name of claimant • Date of accident • Location of accident • Amounts paid and reserved • Narrative detail on the cause of the accident and resulting injury • VWC claim number

_____ The list of subsidiaries and locations is enclosed. _____ The Employer Identification Number (EIN), also known as the Federal

Employer Identification Number (FEIN), is listed for ALL companies, subsidiaries, or operating entities with operations in Virginia.

_____ The most recent audited financial statement or annual report is enclosed (if provided

earlier, give date mailed).

I certify that all information provided is correct to the best of my knowledge.

My typed name below shall have the same force and effect as my written signature for all purposes under Virginia law including the Virginia Workers’ Compensation Act, and any Rule or Regulation of the Virginia Workers’ Compensation Commission. Preparer’s Signature ___________________Title___________________ Date ___________

1. Contacts: corporate, claims processing, and designated representative The #1 address is for the person we will contact regarding basic issues of self-insurance, the #2 address is the address to which all routine mail regarding claims will be sent, and the #3 address is for the in-state designated representative. The #3 address must be a street address within Virginia. #1 Corporate representative:

Name of corporate representative: Title of corporate representative: Address:

PHONE: FAX: E-Mail Address:

#2 Claims processing contact(s):

Name of designated adjuster (if applicable): Name of company: Address of company:

PHONE: FAX: E-Mail Address:

Change from prior year Survey? Yes No If yes: Date of Change ______________

Will Handle Previous Claims? Yes No #3 In-State Designated representative (street address in Virginia is required):

Name of designated representative: Name of company (if applicable): Address of In-State Designated representative PHONE: FAX: E-Mail Address:

Change from prior year Survey? Yes No If yes: Date of Change ______________

Will Handle Previous Claims? Yes No 2. Parent Corporation and Subsidiaries A. List the name and the Employer Identification Number (EIN) of all companies, subsidiaries, or operating entities with operations in Virginia that are included under the Virginia certificate of Self-Insurance (use separate sheet of paper if needed). Include the name of the parent corporation even if the parent has no operations in Virginia.

B. List the name and the Employer Identification Number (EIN) of all parent corporation, subsidiary company, or other operating entity with operations in Virginia that are to be excluded from the Virginia Certificate of Self-Insurance for your company (use separate sheet of paper if needed). C. List and explain any changes to your core operation since the last survey (as an example, if your business is a retail store front and you enter into food manufacturing provide the new operation).

D. Has any state rejected, revoked, or not renewed Self-Insurance privileges in the past 5 years? Yes No If answered yes, list the state and give explanation and date of action. 3. Locations and employees grouped by Employer Identification Number (EIN) A. For all locations list the name, address, nature of operations, and number of employees. Page 5 of the survey includes form “ 2019 List of Subsidiaries and Locations” for your use. Example: Federal Location Street Zip Nature of Number of Tax ID Name Address City State Code Operations Employees 54-1111111 ABC Variety 123 ABC Street Anytown VA 12345 Retail sales 15

B. If you have closed a location since the last annual survey and have not advised the Virginia Workers’ Compensation Commission of the closure, list the location and give the closing date for that location on this report (use separate sheet of paper if needed).

4. Securities and guarantees In addition to providing the information below, you should provide copies of certificates of insurance for excess coverage. Excess coverage

Effective date: Expiration date:

Carrier:

Policy Number: Limits: Specific Aggregate

Retention level

Limit of indemnity Deductible Sixty (60) day advance notice of cancellation ___ Yes

5. Virginia Claims Experience Complete the claim forms attached; Page 6: Claim Summary Addendum for 2019 Annual Survey Page 7: Detailed Claims Addendum for Claims in excess of $100,000 The current year is not considered a complete year.

Self-Insurance Survey for 2019: page 5 series. VWC Form No. SI 23 A (Rev. 5/1/15)

Self- insured Company Name:

Self-insurance Number:

Federal Tax ID Location Name Street Address City State Zip CodeNature of Operation

Number of Employees

Self-Insurance Survey for 2019: Page 6. VWC Form No. SI 23 A (Rev. 5/1/15)

Self-insured Number

Valued as of

2018 2017 2016 2015 2014 2013 2012 2011 2010

a) Closed Claimsb) Open Claimsc) Total claims (a+b) 0 0 0 0 0 0 0 0 0d) Lost Time cases

e) Compensationf) Medicalg) Otherh) Total (e+f+g) $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

i) Compensationj. Medicalk. Otherl) Total (i+j+k) $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

m) Total IBNR Reserves

n) Total (h+l+m) $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Payroll in VirgniaNumber of VA LocationsNumber of VA Employees

Virginia Payroll, Locations, Employees

Number of Claims

Payments

Reserves

IBNR Reserves

Total Incurred

2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997

0 0 0 0 0 0 0 0 0 0 0 0 0

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984

0 0 0 0 0 0 0 0 0 0 0 0 0

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

1983 1982 1981 1980 1979 1978 1977

0 0 0 0 0 0 0

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Virginia Claims ExperienceDetailed information of claims paid and/or reserved at equal to or greater than $ 100,000

Self-Insurance Survey for 2019: page 7VWC Form No. SI 23A (Rev. 5/1/15)

VWC CLAIM NUMBERCLAIMANT NAMEACCIDENT

DATELOCATION OF

ACCIDENTLOSS DESCRIPTION

COMPENSATION PAYMENTS

MEDICAL PAYMENTS

OTHER PAYMENTS

TOTAL PAYMENTS

COMPENSATION RESERVES

MEDICAL RESERVES

OTHER RESERVES

TOTAL RESERVES TOTAL INCURRED

0 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 0

This is a cumulative report. Report both open and closed claims (from 2006 to current). For years 2005 and older, only report open claims.

0 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 00 0 0

0 0 00 0 00 0 00 0 00 0 00 0 00 0 0

commonwealth of virginia virginia …...self-insurance survey for 201: page 9 1 of 7. vwc form no....

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