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Instructions: Private Self Insurer'S Annual Report - 2000 - Department Of Industrial Relations

State of California

Department of Industrial Relations

Self Insurance Plans

2265 Watt Avenue, Suite 1

Sacramento, CA 95825

Phone: (916) 483-3392 — Fax: (916) 483-1535

Web site —

E-mail: sip@dir.ca.gov

INSTRUCTIONS:

PRIVATE SELF INSURER’S ANNUAL REPORT

Year Ending December 31, 2000

General Information

The annual report form, Form A4-40a, is for the self insurer in the private sector. This report

must be completed and returned to Self Insurance Plans by March 1, 2001.

SIP is sending one preprinted annual report form to each self insurer with page 1 partially

completed. The preprinted information should be verified for accuracy, and any errors in the

preprinted material should be marked in ink on the report.

SIP needs two completed reports. At least one report must be on goldenrod legal size paper with

the original signature by the self insurer on page 6, Deposit Calculation, and an original signature

of the claims administrator on the reverse side of page 2, Consolidated Liabilities, and on the

reverse side of each page 3, Liabilities by Reporting Location.

You may send a computer-generated facsimile following our format of the report form or any

other page, provided the original signature is on legal size paper of the correct color. The other

set may be photocopies on white legal size paper—remember, the forms are two-sided.

Also submit two sets of the List of Open Indemnity Cases, and the Specific Excess Insurance

Policy Coverage pages.

The reports are due March 1, 2001 at Self Insurance Plans. We will accept the reports from

January 2 to March 1 of each year.

Please send a copy of the self insurer’s current financial statement when it becomes available.

If you have any questions, please contact Self Insurance Plans.

Instructions: Page 1—preprinted/to be completed by self insurer

Verify the certificate number.

Instructions: Private Self Insurer'S Annual Report - 2000 - Department Of Industrial Relations