Instruction outstanding death 2025

1. Click ‘Get Form’ to open the instruction outstanding death document in the editor.
2. Begin by listing all outstanding self-insured death claims on Form SI-4. Ensure that each claim is valued as of September 30, 2016, and organized in descending order based on the date of accident.
3. Group claims by accident year, starting with the most recent (April 1, 2015 - March 31, 2016) and moving backward. Claims prior to April 1, 2008 should be categorized under an 'all prior years' group.
4. For Form SI-4.1, include totals for disability and medical reserves on each page. Make sure to total these reserves for each accident year at the end of the respective section.
5. If any claims have been adjusted by the Self-Insurance Office, ensure they are reserved according to those adjustments. Include all workers’ compensation accidents entitled to benefits while excluding medical treatment-only cases.
6. Affirm and sign Forms SI-4 and SI-4.1 by an authorized officer of your organization. If additional pages are necessary, only complete the affirmation on the top page.

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